Abstracts

Rationale: Cotard’s syndrome is a rare and severe form of nihilistic delusion characterized by false belief in which there is denial of one’s own existence. The typical natural course of this delusion involves the steadfast belief that the patient is dead, and/or a belief in someone having taken out and replaced their internal organs without leaving a scar. This syndrome is usually encountered in people afflicted with psychosis, as in schizophrenia. The presence of this phenomenon in the setting of postictal psychosis is an extremely rare complication of seizure disorders. Methods: We describe a 42-year-old, right-handed male with long-standing history of primary epilepsy characterized by complex partial seizures with secondary generalization, who presented to the hospital with breakthrough seizures in the setting of acute infection. Initial CT of the brain was unremarkable, however a lumbar puncture showed an opening pressure of 52 cm H2O. Cerebrospinal fluid profile displayed a normal cell count and borderline low protein (18.4 mg/dl). Patient was initially treated with broad spectrum antibiotics for concern of meningitis, subsequently only acyclovir was continued. Despite initial treatment with levetiracetam, patient continued to have frequent events (up to 30 daily). Events were stereotypic characterized by left gaze version followed by left head torsion, flexion of right arm and leg and extension of left arm with tonic-clonic posturing. Symptoms remitted spontaneously and in between episodes, the patient had a normal neurological exam following commands and answering basic questions. As levetiracetam was weaned off, lacosamide and phenytoin were added. Although there was decreased seizure frequency, patient became paranoid and delusional on day 4 post-admission. He believed his internal organs and his stomach were missing and reported feeling “empty inside.” Valproic added was later added for seizure control as well as mood stabilization. Results: An MRI of the brain with and without contrast showed enhancement within the sulci in the parietal and occipital regions concerning for underlying meningitis. Electroencephalogram showed right hemispheric dysfunction, with right frontal epileptogenicity and multiple seizures with a right occipito-temporal onset. Repeat lumbar puncture showed an opening pressure of 16 mm H2O. When the seizures were successfully controlled with lacosamide 100 mg twice a day, phenytoin ER 200 mg twice a day and valproic acid ER 750 mg twice a day, the patient’s mental status returned to baseline. Conclusions: Cotard’s syndrome is thought to result from lesions in the right (or non-dominant) frontal lobe, which could disrupt the anatomic connection between temporal and limbic regions with the frontal lobe; this disconnection is reported to cause a disturbance in familiarity of self, people, places and objects (4). Our patient had right hemispheric dysfunction and right frontal epileptogenicity, which could explain why he developed this rare condition. It is also important to mention that the patient received with acyclovir for treatment of aseptic meningitis. High serum concentrations of CMMG (carboxymethoxymethylguanine), the principal metabolite of acyclovir, have been associated with Cotard’s delusions, nevertheless, this often seen in patients with renal disease. There is no specific treatment for Cotard’s syndrome; the general approach for treatment involves treating the underlying medical or neuropsychiatric illness in all cases. Funding: No funding