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A distraught elderly man brings his equally elderly wife to the ER on a Friday night for behavior problems. “I can’t do anything with her,” he says. Apparently she has been yelling at him for several days non-stop, and in the last 24 hours she has become physically abusive. A screening medical history reveals that she has “Alzheimer’s” and hypertention, and is only on BP medication. Vitals are P 115, BP 115/65, RR 24, sat 96% RA, afebrile. On exam she makes eye contact and reaches out a hand with gothic-length fingernails to grab you by the arm. After a brief struggle, you determine that she has normal heart tones, bilateral breath sounds, no abdominal tenderness and no obvious focal neurologic deficit. She will give you her name, but will not answer any questions.

alt Because of her age and history of new “behavior” related problems, you order CT scanning of the head, as well as as electrolytes to rule out a metabolic cause of her symptoms. She has no obvious toxidrome or meds that would cause delirium through their toxicity. There is no obvious source of infection, and no symptoms to suggest a major cardiolpulmonary process (but you order an EKG and cardiac enzymes to be sure). It’s the usual routine in clearing an elderly psych patient, but important as the symptoms are new and acute. The typical psych patient is young (not old), has a prior history of psych illness, and has subacute (not acute) illness. She is old, you think the symptoms are new, and the illness appears to be acute -- must look for a psych mimic.

alt The psychiatrist has agreed to admit her, and there is a bed waiting. The charge nurse is also waiting, a sympathetic look on his face, holding a syringe filled with Haldol and Ativan for patient sedation. Twenty minutes later, the patient is resting comfortably on the monitor, O2 and pulse ox, and the lab tech is drawing blood on your geriatric special. A little while later, the CT head is done, and the pysch floor is calling for the patient (they want her tucked-in for the night).

 
You glance at the CT scan while signing the admission paperwork.  What does it show?
See next page for case conclusion.
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alt
Diagnosis:
Temporal lobe vasogenic edema, likely due to metastatic breast cancer


This was a terribly sad case (even for us cynical ER types), and just goes to show that medical illness can be a good mimic of psych problems.  In this case, on further questioning, the patient had a history of breast cancer resected three years ago.  The other important features of the history suggesting non-psych cause of the behavior problems were a sudden onset of symptoms, and no prior psych illness (although we had attributed the behavior problems to the known Alzheimer’s disease). 

Needless to say, the CT scan is very abnormal.  There is a large amount of presumably vasogenic edema in the left temporal lobe, with mass effect and a suggestion of a mass, consistent with a late metastasis from the previously diagnosed breast cancer.  The  temporal location of the metastatic tumor likely accounts for the illness manifesting itself with aggression and behavior problems, rather than focal weakness or headache.  Treatment is IV steroids and referral to medical and neurosurgical team for diagnosis and treatment. 

Dr. Dallara directs the Emergency
Medicine PREP Course. 
 

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