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Psych Congress  

Can Steroids Cure Mania?

Priti Patel, MD
Amit Bhakhri, MD
Nitin Chopra, MD
Abner Rayapati, MD, MPH
Meagan Whitney, BS

Delirium secondary to an underlying medical condition is a common phenomenon with a broad spectrum of etiologies, which at times can remain undiagnosed. As an example, a 65yo woman who presented with paranoid delusions and mania was admitted by internal medicine for Altered Mental Status. Common etiologies were ruled out and psychiatry was consulted for concern for a primary psychiatric diagnosis. Psychiatry advised continued search for rare etiologies with assistance from neurology, along with initiation of Risperidone. It was found that her thyroid function was impaired while TPO antibody and striated muscle antibody titers were elevated. This suggested a possible diagnosis of Hashimoto's autoimmune encephalitis. Since several weeks of antipsychotic treatment had yielded no clinical improvement, this was discontinued and a trial of high-dose steroids was initiated. Rapid improvement in her psychiatric symptoms was demonstrated, but mania and paranoia would promptly return when steroids were tapered. Over 6 months, she was hospitalized 3 times for these symptoms with various providers, multiple differential diagnosis and treatments with symptomatic relief obtained only from high-dose steroids. The resistance of her symptoms to antipsychotics, combined with her autoimmune antibody titers, and clinical improvement on steroids is suggestive of an underlying autoimmune encephalopathy. Thus, this case study serves not only to promote awareness of autoimmune encephalopathy and its comorbid psychiatric manifestations, but also to exemplify a rare case which could have remained undiagnosed had clinical curiosity not prevailed.

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