Table of Contents - Academy of Psychosomatic Medicine

consciousness and mild disorientation. Despite her altered
mental status, we were able to obtain a history concerning
for antifreeze ingestion. The renal biopsy confirmed the diagnosis
and the patient later admitted to the ingestion.
Conclusions: This case is important because it is the first
reported case of chronic ethylene glycol poisoning as a
method of self-harm and it underscores the importance of a
detailed review of the history in the evaluation of delirium.
Early recognition of ethylene glycol poisoning is essential for
proper care including prompt treatment with fomepizole.
30. A Case of Cerebellar Cognitive Affective
Syndrome Treated with Olanzapine
Presenting Author: Jason Caplan, MD
Co-Author: Gunjan Parikh, MD
Introduction: Recent investigations have revealed that the
cerebellum is involved in more than its previously postulated
function of the coordination of movement. It has been suggested
that the cerebellum has an integral role in the regulation
of cognitive and emotional processing, with cerebellar lesions
resulting in a constellation of symptoms that has been
termed the cerebellar cognitive affective syndrome (CCAS).
Despite this evolving contemporary body of evidence, no
clear pharmacological strategies have been developed for
the management of CCAS.
Case Report: A 64 year-old man with no prior psychiatric
history was admitted with ataxia, diplopia, weight loss,
and poor self-care worsening over the preceding several
months. He was found to have a left upper lobe lung mass
diagnosed as adenocarcinoma with another mass centered
in the cerebellar vermis and extending into the cerebellar
hemispheres. After craniotomy and resection (confirming
metastatic disease), psychiatric consultation was requested
for persistently bizarre behavior. On exam, he was found
to have intact cognition, an expansive affect and prominent
paranoid and grandiose beliefs - accusing the nursing staff
of poisoning and physically assaulting him, and calling an attorney
from the bedside. His odd behavior included the collecting
and careful arrangement of urinals on the floor of his
room. He had not been treated with steroids and there was
no evidence of delirium on exam. On evaluation, the onset
of psychotic behavior and expansive mood immediately after
the resection of a large cerebellar lesion were thought to be
most consistent with cerebellar cognitive affective syndrome
(CCAS). Olanzapine 5mg twice daily was started, which the
patient tolerated well. At one month follow-up, his paranoia
had resolved and his executive functioning, reasoning, and
mood had dramatically improved.
Discussion: The abnormal behaviors seen with CCAS are
marked by inappropriate (either excessive or diminished) responses
to the environment analogous to the over- and undershoot
of movement resulting from cerebellar lesions. The
cerebellum is an important way station in the complex neural
circuitry subserving cognition and emotion. It is important in
patients with cerebellar dysfunction to carefully assess for
cognitive and affective disturbance to allow for timely diagnosis
and treatment of this syndrome. Further investigation
is warranted to establish the benefit of olanzapine and other
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psychotropic medications in the treatment of psychiatric disturbances
associated with CCAS.
31. Posterior Reversible Encephalopathy
Syndrome: Delirium with Unique
Neuroradiologic Features
Presenting Author: Jason Caplan, MD
Co-Author: Gunjan Parikh, MD
Introduction: Posterior reversible encephalopathy syndrome
(PRES) is a state of neurotoxicity with a characteristic
watershed imaging pattern of cerebral edema that is common
to a number of complex acute systemic conditions. Delirium
is a presenting symptom in nearly all cases of PRES.
Little mention has been made in the psychiatric literature of
this increasingly recognized syndrome. This poster will describe
the clinical presentation and exhibit the neuroradiologic
features associated with PRES.
Discussion: PRES has been most commonly described in
association with severe hypertension, toxemia of pregnancy,
and with cyclosporine immunosuppression after organ transplantation,
however, the syndrome has been increasingly
reported in other conditions, including sepsis, autoimmune
diseases, and in the context of cancer therapy. Patients typically
present with encephalopathy, seizures, a spectrum of
visual deficits (including cortical blindness), and headache.
Given that the clinical presentation is often non-specific,
PRES has become synonymous with a unique neuroimaging
pattern on magnetic resonance imaging. The basic
PRES pattern resembles symmetric hemispheric edema in
brain watershed zones with the parietal and occipital lobes
most commonly affected. The mechanism of PRES remains
unknown. The current favored theory based on animal studies
suggests that severe hypertension exceeds the limits of
cerebral autoregulation resulting in injury to the capillary bed
and hyperperfusion which manifests as vasogenic edema
on neuroimaging. Since PRES has now been reported in the
absence of hypertension, an alternative theory (involving inflammatory
cytokine response associated with vasoconstriction
and hypoperfusion) is gaining traction.
Conclusion: The encephalopathy of PRES represents a
subtype of delirium with unique neuroradiological features. It
is important that consultation psychiatrists are aware of this
phenomenon to aid in its timely diagnosis and treatment.
32. Paraneoplastic Encephalitis in a Patient
with Mature Ovarian Teratoma and NMDA
Receptor Antibodies
Presenting Author: Diana Domnitei, MD
Co-Author: Junji Takeshita, MD
Purpose: We describe a 20-year-old patient with paraneoplastic
encephalitis, N-Methyl-D-aspartate (NMDA) receptor
antibodies and mature ovarian teratoma (OT).
Methods: Diagnosis, management, including psychiatric
management, hospital course, and current literature is
described.