FRI202 A Curious Case Of Psychosis
Authors: Waqar Fatima , Arif Ansharah , Muazzam Asmaa , Wadood Romaisa , Khakwani Aemen Shams , Khan Usman Ahmed 
Published: October 2023

Abstract
Disclosure: F. Waqar: None. A. Arif: None. A. Muazzam: None. R. Wadood: None. A.S. Khakwani: None. U.A. Khan: None.
Ascertaining the cause of mental and behavioral changes can be challenging in patients with complex medical histories. We are sharing a thought-provoking case of psychosis. A 51-year-old woman with past medical history of ESRD, stroke, diabetes, depression, and endometrial cancer was brought to the hospital for lethargy and confusion. It was preceded by some nausea, vomiting, and abdominal pain. Upon admission, she was noted to be hypotensive and minimally responsive. She was given fluids (with subsequent improvement in blood pressure) and started on antibiotics empirically for concerns of sepsis. During her hospital course, her mental status fluctuated from being completely normal to having episodes of becoming still, with total lack of response to any stimulus. During these episodes, she would be awake, breathing spontaneously and vitally stable, but unresponsive, mimicking catatonia however lacked muscle stiffness/ rigidity. Each episode resolved spontaneously after a few hours. Multiple CT scans and a CT Angiogram of the Head & Neck were negative for acute findings. Continuous EEG revealed no epileptic activity. Infectious work-up was unrevealing. Labs were within the expected range of the intra-dialytic period. Two of her medications, gabapentin and mirtazapine were thought to be the contributors and were stopped upon admission, however with little improvement. Her symptoms were ultimately deemed to be psychogenic in origin, and she was started on an anti-psychotic regimen. Fortunately, as part of her workup, a morning cortisol level was checked, which resulted to be quite low at 1.6 mcg/dL, consistent with adrenal insufficiency. Co-syntropin stimulation test confirmed adrenal insufficiency, the actual cause of her presentation. This explained her intermittent hypotension along with mental and behavioral changes. Interestingly, she was found to be on megestrol acetate which is notorious for causing secondary adrenal insufficiency. She was ultimately started on hydrocortisone replacement therapy, with subsequent improvement and stabilization of her mental status, mood, and behavior; and was discharged with outpatient Endocrinology follow-up. This case highlights the importance of the broad differentials to consider for mental and behavioral changes. We want to alert physicians to include adrenal insufficiency in the differentials of acute psychosis as symptoms and electrolyte abnormalities may be atypical and masked in dialysis patients. The exact mechanism of neuropsychiatric symptoms (which may precede metabolic abnormalities) is unknown but is hypothesized to involve elevated levels of endorphins and electrophysiological disturbances as glucocorticoid receptors are widely distributed in the brain, specifically in the hippocampus. Megestrol is an established cause of secondary adrenal insufficiency, and monitoring is essential with long-term use.
Presentation: Friday, June 16, 2023