First-presentation with psychotic behavior to the Emergency Department: Meningitis or not, that is the question.

INTRODUCTION: Meningitis is a potentially life threatening medical emergency. Psychotic behavior may be a presenting feature in patients with meningitis. We aimed to determine the value of various clinical and laboratory features at ruling-out meningitis in the patient presenting with a first-episode of psychotic behavior. METHODS: Medical records of 159 subjects presenting to a tertiary academic hospital over a 6-month period with one or more psychotic features for the first time were prospectively gathered. Pathological cerebrospinal fluid findings as well as clinical and other laboratory findings were tabulated and discussed retrospectively. RESULTS: Cerebrospinal fluid was obtained in 153/159 (96.2%) subjects. Meningitis was confirmed in twenty-eight (18.3%) subjects. Of these, a) one or more clinical feature of meningitis (headache, neck stiffness, photophobia or focal neuropathy) was present in 21 subjects (75.0%), b) visual hallucinations in 15 subjects (53.6%), c) pyrexia >37.5 °C in 7 subjects (25.0%), d) CRP >10 mg/L in 21 subjects (75.0%), e) HIV seropositive status in 19 subjects (67.9%) and f) an absence of illicit substances on urinalysis in 23 subjects (82.1%). Various combinations of these variables, where the presence of ≥1 variable was regarded as positive, were unable to rule-out meningitis in all study subjects. CONCLUSION: The absence of these six parameters; alone or in various combinations, was unable to rule-out meningitis in all patients presenting to our ED with a first-episode of psychotic behavior. When the underlying etiology of psychotic behavior is not obvious, the clinician should adopt a low threshold to perform a lumbar puncture.

First Presentation with Psychotic Symptoms to the Emergency Department.

BACKGROUND: Mental health conditions account for 52.8 million (4.9-6.3%) emergency department (ED) visits in the United States. Psychotic conditions are responsible for approximately 10% of all mental health presentations. OBJECTIVE: We aimed to determine the underlying etiology and characteristics of patients presenting to the ED with a first episode of psychotic symptoms. METHODS: Medical records of 159 African, Asian, white, and mixed-race patients were prospectively reviewed. Subjects were classified into one of three groups; psychosis due to an underlying medical condition (UMC), substance-induced psychotic disorders (SIPDs), and psychosis due to other primary psychiatric disorders (OPD). Demographic details and presenting features were described and compared. RESULTS: Overall mean (standard deviation [SD]) age of all study subjects was 34.3 (13.4) years. A UMC was responsible for a first presentation with psychotic features in more than half of the study subjects (n = 87 [54.7%]), while SIPD (n = 37 [23.3%]) and OPD (n = 35 [22.0%]) were responsible for the remainder of cases. The majority of subjects were male (n = 95 [59.7%]), unemployed (n = 105 [66.0%]), and had not completed secondary school (n = 109 [68.6%]). More than one-third of subjects tested positive for human immunodeficiency virus infection (n = 63 [39.6%]). Mean (SD) duration of psychotic symptoms before ED presentation was 16.6 (26.3) days. CONCLUSIONS: UMC is a common etiology in patients presenting to the ED with a first episode of psychotic symptoms.