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Journal of Psychology and Clinical Psychiatry
Delirium Precipitated by Polycythaemia
Introduction
Delirium is a common and serious problem among acutely
unwell persons. Although linked to higher rates of mortality,
institutionalization and dementia, it remains under diagnosed.
Careful consideration of its phenomenology is warranted to
improve detection and therefore mitigate some of its clinical
impact. The publication of the fifth edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association (DSM5) provides an opportunity to examine the constructs underlying
delirium as a clinical entity [1]. We are reporting a case of delirium
in a 20 years old female that was precipitated by a secondary
polycythaemia caused by a congenital cardiac left to right shunt
resulting in a pulmonary hypertension.
Our med pub mesh literature search did not yield a previously
reported similar case.
As far as we know we are reporting a first case of its kind.
a. Disturbance in attention (reduced ability to direct, focus,
sustain, and shift attention) and awareness (reduced
orientation to the environment).
Volume 6 Issue 4 - 2016
1
Case Report
Professor of Clinical Psychiatry, Ohio University College of
Medicine, USA
2
Emergency Department, HMC, Doha, Qatar
*Corresponding author: Adel Sleiman Zaraa, Professor of
Clinical Psychiatry, OUCOM, Ohio, USA, Po Box 3050, HMC,
Department of Emergency, Doha, Qatar, Tel: +974 33427277; Email:
Received: September 07, 2016 | Published: September 16,
2016
DSM classifications of delirium
d. The disturbances in Criteria A and C are not better
explained by another preexisting, established, or evolving
neurocognitive disorder and do not occur in the context of a
severely reduced level of arousal, such as coma.
It was reported in numerous papers that Polycythaemia Vera
has been a regular but not so common etiology of delirium as
reported by Polycythaemia, delirium and mania [3]. But our review
of literature yield much less reports of Delirium precipitated by
secondary Polycythemia, found in Erythremia (polycythemia)
with a psychosis erythremia was one of the factors responsible
for the appearance of the psychosis [4]. Here we are presenting
the case of 20 years old, new bride who arrived from his country
of origin 3 weeks before admission to the Hospital. The marriage
was arranged and the family of the husband has no past history
of the woman mental or physical status. They presented to the
Emergency Room with her family due to change in her behavior
and a consistent headache for the last one week. The Patient was
fearful, anxious and at times confused, disoriented to time, place
and person.
While there was no denial of the organic etiology of delirium,
based on a huge body of references that surpassed million hits
related to the subject. The etiologies of delirium are diverse
and multifactorial and often reflect the pathophysiological
consequences of an acute medical illness, medical complication
or drug intoxication. Delirium can have a widely variable
presentation, and is often missed and under diagnosed as a result
[2].
Prior to her presentation to Emergency her family took her to a
traditional healer which left superficial marks on her scalp with no
improvement. The Psychiatrist on call cleared her from their side
and recommended to have Medical consultation. The initial basic
blood investigation showed an unexplained and serious elevation
in her hematocrit (70) and Hemoglobine (18’7), MCV (75’8). So
she was admitted to the Medical ward for further investigation
where a Hematologist, a Cardiologist and a Neurologist were
consulted.
b. The disturbance develops over a short period of time (usually
hours to a few days), represents a change from baseline
attention and awareness, and tends to fluctuate in severity
during the course of a day.
c. An additional disturbance in cognition (e.g. Memory deficit,
disorientation), language, visuospatial ability, or perception
that is not better explained by a preexisting, established, or
other evolving neurocognitive disorder.
e. There is evidence from the history, physical examination,
or laboratory findings that the disturbance is caused by the
physiological consequence of another medical condition,
substance intoxication or withdrawal (i.e., due to a drug of
abuse or to a medication), or a toxin exposure, or is due to
multiple etiologies.
Submit Manuscript | http://medcraveonline.com
Polycythaemia and delirium
Psychiatry was consulted and the initial evaluation reported
that she didn´t show any sign or symptom of mood or psychotic
disorder during the interview. She was with poor concentration,
poor attention span, forgetful. She was having episodes of
confusion, disorientation and incoherence with fluctuations.
J Psychol Clin Psychiatry 2016, 6(4): 00369
�Copyright:
©2016 Zaraa et al.
Delirium Precipitated by Polycythaemia
During admission 2 venesections were done, secondary causes
of Polycythemia were investigated, pulmonary hypertension
was found and other causes such as Viral infections and renal
diseases were excluded. CT venogram, CT head and Chest X-ray
were normal. Echocardiography showed a severe pulmonary
hypertension, EF 55-60 %, right ventricle was moderately
enlarged, the right ventricular systolic function was moderately
impaired. She was diagnosed as Delirium secondary to general
medical condition, Polycythaemia secondary to pulmonary
hypertension (due to a congenital right to left heart shunt).
She was further hospitalized for four days, treated with one mg
of haloperidol twice a day and exsanguinations as ordered by
medicine; her orientation improved and was discharged with
outpatient clinic appointment for further investigation of possible
cause of Pulmonary Hypertension due to Congenital Heart
disease. She was started on low dose Haloperidol that helped
but the dramatic response was with exsanguinotransfussion.
Improvement in alertness correlated very well with the increase
in cerebral blood flow which followed venesection [5].
Conclusion
We need to be aware that a secondary polycythemia can
cause delirium such as found in heavy smokers, chronic COPD
patients and residents of high elevations mountains, as presented
in Mountain sickness [6], Smoking as a cause of erythrocytosis
2/2
[7]. The management of Polycythaemia secondary to pulmonary
hypertension needs to be multidisciplinary due to several
possible etiologies; thus an inclusive differential diagnosis would
be prudent standard of care in cases of delirium in non risk prone
population.
References
1. European Delirium Association and American Delirium Society
(2014) The DSM-5 criteria, level of arousal and delirium diagnosis:
inclusiveness is safer. BMC Medicine 12: 141.
2. Tamara G Fong, Samir R Tulebaev, Sharon K Inouye (2009) Delirium
in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol
5(4): 210-220.
3. Chawla M, Lindesay J (1993) Polycythaemia, delirium and mania. Br J
Psychiatry162: 833-835.
4. Levin M (1938) Erythremia (polycythemia) with a psychosis. Am J
Psychiatry 10: 407-410.
5. Willison JR, Thomas DJ, du Boulay GH, Marshall J, Paul EA, et al. (1980)
Effect of high haematocrit on alertness. Lancet 1(8173): 846-848.
6. Bultas J (2015) Mountain sickness. CasLekCesk 154(6): 280-286.
7. J Moore-Gillon (1975) Smoking as a cause of erythrocytosis. Ann
Intern Med 82(4): 512-515.
Citation: Zaraa A, Miquel MAR, Ahmad M (2016) Delirium Precipitated by Polycythaemia. J Psychol Clin Psychiatry 6(4): 00369. DOI:
10.15406/jpcpy.2016.06.00369
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Delirium Precipitated by Polycythaemia.
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Zaraa A, Miquel MAR, Ahmad M
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Adel S. Zaraa, MD
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Journal of Psychology & Clinical Psychiatry
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2016
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delirium, polycytemia
Description
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Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalization and dementia, it remains under diagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM- 5) provides an opportunity to examine the constructs underlying delirium as a clinical entity [1]. We are reporting a case of delirium in a 20 years old female that was precipitated by a secondary polycythaemia caused by a congenital cardiac left to right shunt resulting in a pulmonary hypertension. Our med pub mesh literature search did not yield a previously reported similar case.
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<a href="http://doi.org/10.15406/jpcpy.2016.06.00369" target="_blank" rel="noreferrer noopener">10.15406/jpcpy.2016.06.00369</a>
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journalArticle
delirium
Department of Psychiatry
Ehassan NM
Miquel MAR
NEOMED College of Medicine
polycythaemia
Zaraa AS