Demanding diagnostics – important diagnosis

Øivind Ekeberg About the author

There is little probability of a healthy patient who has not previously had psychiatric problems becoming manic in her late 50s without there being an organic reason for it.

The somatic diagnostics may be demanding. It is necessary to examine possible neurological, metabolic, medicinal and intoxicant-related causes. The patient had early symptoms such as impaired strength and unsteady gait which pointed in a neurological direction. Many conditions do not show up on a CT or, less commonly, on an MRI either. A lumbar puncture should be performed early.

Antibodies develop slowly in borreliosis, and serological tests are frequently negative, particularly in the early stages of the disease (1). The incubation period may be long, so that in many cases the patient is not aware of exposure. The diagnostic challenges can be illustrated by the fact that the disease is also called «the new great imitator». Neuroborreliosis has become the most frequently occurring neuroinfectious condition in Europe where the source of infection is a vector (2). The prevalence is increasing, probably partly due to vegetation changes and a milder climate.

The most common psychiatric symptoms are tiredness and depression, but panic attacks, schizophrenia-like symptoms and hallucinations may also occur (2).

The patient was hospitalised two months later on suspicion of depression, but the diagnosis was not confirmed. However, she was suffering from tiredness, a common sequela that can last a long time. After completion of treatment, regional hypoactivity with respect to blood supply and metabolism was also found, particularly in the temporal and parietal lobes and in the limbic system (3).

In addition to neurological and psychiatric symptoms, skin manifestations in particular are common, but the heart and limbs may also be affected.

Although the prognosis is normally good, a sneaking development may mean that more areas of the brain may be affected before diagnosis and treatment, resulting in a protracted course for the disease.

The treatment may be difficult because the bacterium has developed many defence mechanisms. The treatment is often successful if it is applied early, but a chronic infection may be difficult to treat (1).

Early diagnosis and treatment is important with a view to shortening both the course of the active disease and the restitution period. Since the symptoms presented can be so variable, it is useful for rare cases, such as the present one, to be published.

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