PSYCHIATRIC MANIFESTATIONS OF ADULT-ONSET STILL’S DISEASE AND TREATMENT CONSIDERATIONS
INTRODUCTION: Adult-Onset Still’s Disease (AOSD) is a rheumatologic disorder characterized by quotidian fevers, arthritis, arthralgias, tachycardia, and evanescent rash. Rarely, psychiatric symptoms are reported. Although etiology and pathophysiology is still unknown, treatment includes a prolonged course of corticosteroids that could precipitate or exacerbate psychiatric symptomatology such as mood dysregulation and/or psychosis. Here we observe how the treatment of rheumatologic disorders can manifest into neuropsychiatric symptoms.
CASE PRESENTATION: The patient is a 32 year old Caucasian female with a past medical history significant for rheumatoid arthritis and a psychiatric history of postpartum depression who was initially admitted to the psychiatric unit for evaluation of bizarre behavior, auditory hallucinations, and delusional thought content. She was transferred to the medical service for persistent tachycardia, fever, disorientation, bilateral wrist swelling, and arthralgia. A thorough workup was conducted which ultimately led to a diagnosis of AOSD. Yamaguchi & Fautrel’s Criteria were utilized in diagnosis. Prednisone 60mg daily was started and she was medically stabilized. However, she was not near her baseline and was subsequently transferred to the psychiatric unit. On admission, the patient exhibited symptoms consistent with manic episode with psychotic features (auditory hallucinations, paranoid delusions). Prednisone taper was continued. We initiated treatment with risperidone and valproic acid. The patient began showing a slight improvement over the course of four days while titrating risperidone. This improvement continued after the addition of valproic acid. The patient was monitored for 7 days after starting valproic acid and at discharge exhibited significant improvement in mood stability, thought process, and resolution of psychosis. The patient continued treatment with risperidone, valproic acid, and prednisone taper following discharge. Review of outpatient documentation indicates that since completing the prednisone taper she has not experienced a relapse of these symptoms.
DISCUSSION/CONCLUSION: Psychiatric symptoms such as those described above are very rarely reported in literature regarding AOSD. However, a well known adverse effect of systemic corticosteroid treatment is the potential to precipitate a variety of psychiatric and cognitive symptoms even in patients without a history of psychiatric disorders. The incidence of symptoms varies depending on dose.
It is difficult to determine a solitary precipitating factor for the patient’s reported psychiatric symptoms and as such multiple factors likely played a role. The patient may have been exhibiting neuropsychiatric symptoms associated with AOSD. This is reinforced by reported failure to respond to therapy with atypical antipsychotic monotherapy prior to this admission and significant improvement with combination therapy involving high dose oral prednisone and subsequent taper, risperidone, and valproic acid. Exacerbation of mania and psychotic symptomatology coincides with initiation of high dose prednisone and their continued improvement with completion of the prednisone taper reinforces this idea. This case underlines the importance of recognizing and treating psychiatric symptoms in patients with rheumatologic conditions, especially those on high dose systemic corticosteroids. Improvement with a standard therapy for bipolar I disorder suggests that the psychiatric manifestations should be managed similarly to the primary psychiatric disorder.
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