ABSTRACT
A 50-year-old man with multiple psychiatric comorbidities including major depressive disorder and general anxiety disorder presented to the emergency room (ER) with altered mental status, immobility and mutism. The patient was unresponsive to commands and unable to provide any history. In the ER he was given a provisional diagnosis of cerebrovascular accident (CVA). Vital signs on admission were stable. On physical examination, he exhibited grimacing, muscle rigidity and areflexia. Workup for CVA and infectious aetiology was unremarkable and the patient's urine toxicology screen was negative. History from the patient's family revealed that 4 days prior to presentation, the patient had discontinued his prescribed dose of alprazolam 1 mg four times per day. The patient was diagnosed with catatonia due to benzodiazepine withdrawal and had gradual return to baseline with administration of lorazepam 1 mg intravenous three times per day.
Subject(s)
Alprazolam , Antipsychotic Agents , Catatonia/chemically induced , Patient Compliance/psychology , Psychotic Disorders/drug therapy , Self Medication/adverse effects , Substance Withdrawal Syndrome , Alprazolam/administration & dosage , Alprazolam/adverse effects , Antipsychotic Agents/administration & dosage , Antipsychotic Agents/adverse effects , Catatonia/drug therapy , Catatonia/psychology , Comorbidity , Humans , Lorazepam/therapeutic use , Male , Middle Aged , Psychotic Disorders/complications , Psychotic Disorders/physiopathology , Self Medication/psychology , Substance Withdrawal Syndrome/psychology , Treatment OutcomeABSTRACT
Adult T cell lymphoma (ATL), is a peripheral T cell neoplasm associated with infection by human T-lymphotropic virus (HTLV). This is a case of a 28-year-old lady who presented with back pain for the past month and recent onset weakness in her lower extremities bilaterally. She has a history of T-cell lymphoma secondary to HTLV-1 under remission since 2014 and systemic lupus erythematosus complicated by lupus nephritis. On physical examination patient had hyper-reflexia in both knees, ankle clonus bilaterally and spasticity in both her lower extremities. She also had a diffuse, scaly, macular rash in her upper and lower extremities and ulcer-like lesions on the plantar surface of both feet. Her lumbar puncture showed lymphocyte predominance. The Western Blot test was positive for HTLV antibodies in the CSF. The patient was started on IV Methylprednisone which considerably improved her symptoms. The biopsy of her skin lesions showed an immunophenotype of T-cells similar to the cells in the bone marrow at the time of diagnosis of the lymphoma. HTLV infection is an etiologic agent for ATL as well as for tropical spastic paresis. One should have a high degree of suspicion for tropical spastic paresis in patients with HTLV-1 infection as it can easily go undiagnosed. Indolent forms of ATL can also present in the form of skin lesions in later stages. It is also important to distinguish between skin manifestations of ATL and cutaneous T cell lymphomas, and the importance of skin biopsies for the same cannot be undermined.
