A Case of Cotard Syndrome and Neurosyphilis

ABSTRACT

BACKGROUND: Cotard syndrome is a rare neuropsychiatric condition in which individuals have delusions of being deceased or losing their organs. It is often seen in patients with severe depression and is associated with catatonia.1 Neurosyphilis is a severe sequelae of untreated treponema pallidum infection in which the paretic form of this disorder commonly has a psychiatric presentation. 2 We present a rare case of Cotard syndrome in a patient with neurosyphilis with successful treatment. OBJECTIVE: To understand Cotard syndrome and underlying neuropsychiatric conditions, and characterize the diagnosis and management of psychiatric symptoms in a patient with neurosyphilis. METHODS: Review of a case using electronic medical records and relevant literature. Key terms searched 'Cotard syndrome,' 'neurosyphilis,' 'COVID-19 infection' using Medscape and Google Scholar. RESULTS: We present a 49-year-old male with a history of alcohol use disorder in remission, depression, and history of COVID-19 (asymptomatic) 6 months prior. The patient presented to the emergency department for recent changes in behavior. He was agitated, threatening, and required chemical and physical restraint. Evaluation was notable for illogical thought processes with somatic delusions. He repeatedly stated, 'I am already dead, my organs have died,' and had an episode of catatonia. All tests including drug screen and COVID-19 were negative. Rapid plasma regain (RPR) titer was 164. Neurology and Infectious Disease were consulted. Lumbar puncture revealed positive venereal disease research laboratory (VDRL) titer of 14. The patient was diagnosed with neurosyphilis and major depressive disorder with psychosis with Cotard syndrome. He was treated with intravenous (IV) penicillin G and was discharged on oral mirtazapine 30 mg and olanzapine 20 mg nightly at bedtime, oral donepezil 5 mg daily, thiamine, and folate. CONCLUSIONS: Cotard syndrome is often seen in depression with psychotic features.1 Neurosyphilis can present with depression, anxiety, psychosis, and dementia. Early identification is the key for successful treatment. This is a unique case of neurosyphilis with features of Cotard syndrome in a patient with a history of depression with treatment noncompliance. Studies show that quetiapine and risperidone improve psychosis in neurosyphilis.5 In this case, neurosyphilis was successfully treated with IV penicillin G for 2 weeks. The patient was also tried on antipsychotics and mood stabilizers ' specifically aripiprazole, valproic acid, and haloperidol ' and was eventually stabilized on oral olanzapine 20 mg taken nightly at bedtime. Our differential diagnosis also included COVID-19 delirium with Cotard syndrome, which was ruled out due to a negative COVID test. To our knowledge, there are 2 cases of COVID-19 delirium with Cotard syndrome.6 We present this case to inform clinicians of rare manifestations of neurosyphilis in patients with comorbid psychiatric illness and to advance research into treatment options for psychosis in neurosyphilis.