Confusion: Lost in Translation

We are very excited to be back with season 4!

The Home of Medicine has a new Home - The Royal College of Physicians of Edinburgh, but the podcast is the same as ever, bringing you case discussions and real time clinical decision making. 

In this episode Amie works through a case of confusion, and adopts the 'watch and wait' approach. 

Can you work out the diagnosis before Amie?

Disclaimer: All patient stories discussed in Home of Medicine are informed by real patient interactions. However, all identifying details have been removed or appropriately modified to protect patient confidentiality. 

This podcast is intended for education and professional development and should not replace independent clinical judgement or specialist consultation.

Transcript

SPEAKER_00 0:11

Hello and welcome to the Home of Medicine podcast with me, Dr. Amy Burbridge. I'm a consultant in Ekeet and General Internal Medicine working in the West Midlands in the United Kingdom. Now, this is such an exciting episode because we have a very new home for the Home of Medicine. And the new home is the Royal College of Physicians, Edinburgh. Over to you, Ben Thanks, Amy.

SPEAKER_02 0:42

Hi, Amy. Hi, everyone. My name's Ben Lovell. I am your co-host of the Home of Medicine podcast. I'm also an acute physician and I work in London in the UK. And I'm really excited that we now have a new home for the Home of Medicine. And I want to say, before we do our episode today, welcome any new listeners. And a big thank you to the European Federation of Internal Medicine, which has been our home up till now for the Home of Medicine podcast. And they've really helped, supported us over the years with this podcast and helped us grow it from a gleam in your eye to the really fun and hopefully educational podcast that it is today. So big thanks to Ethan for that.

SPEAKER_00 1:18

Absolutely. Thank you, Ben. And you've got a case for me.

SPEAKER_02 1:23

Are you ready?

SPEAKER_00 1:24

Always.

SPEAKER_02 1:26

Okay. So this is a case that I encountered on the Acute Medical Take and on the AMU a short while ago. And it is the case of a 63-year-old woman. And this woman presented to the Acute Medical Take with an acute confusional state. She is a tourist. She's visiting us from where she lives with her family in Japan. And she was doing a European trip. So she flew from Japan, she went to Paris a few days, then she came to London two days ago. And this is a woman who doesn't speak any English. So she was there with her husband and with her two daughters, her grown-up daughters. And the translation headline was that she's normally very fit and well, but over the last 24-48 hours has developed intense confusion, a little bit of agitation, fearfulness, delusions that she is in trouble, that someone's coming to chase her. And now, as she sits in the AMU, is actually very, very difficult to calm down, is pacing around, is completely unlike her normal self. And she was seen by an emergency medicine doctor and by the liaison psychiatry team down in the emergency department who said that this may be a new psychiatric presentation or this could be an organic problem. However, she needs a further medical workup before we were to make this diagnosis. And now she's my patient. So there is your headline of the case. What are your initial thoughts and reactions? Do you see cases like this?

SPEAKER_00 3:04

Yeah, absolutely. And they are really interesting and also quite challenging as well for many different reasons. Acute confusion or state or delirium can have so many causes. One cause can be multifactorial, and often really getting down to the nitty-gritty of what's causing that acute confusion or state can be quite challenging. It's also difficult when you've got a history taken through a translator because you don't know how many things are lost in translation. And I think that's when our skill comes in, then of observ of observation and actually just observing the individual, observing the family dynamics, and also the real importance of physical examination and how valuable that can be as well. So in front of me, I have a 63-year-old female. Any past medical history of note?

SPEAKER_02 4:02

So the family say the only thing that she takes is a bit of, I think it was amylodopine, and for hypertension. That was her only medication and only past medical history. Otherwise, she she was a fit and well woman. She was retired. She was previously an administrative assistant, no great smoking or alcohol history at all. And she'd never had any kind of confusional state or psychiatric diagnosis made in her life.

SPEAKER_00 4:27

I mean, I first of all I park the psychiatric diagnosis because, like the liaison psychiatrist said, you really need to rule out an organic cause. So I'm going to go back to basics here and try and think about what could cause an acute confusional state in a 63-year-old female. Now you can use different mnemonics here. You can use like a surgical sieve such as vitamin D, or you can look at the causes of delirium, which I use the mnemonic pinch me, and I'm going to talk through those now. So, vitamin D, I'm thinking about vascular causes. So has this patient had an ischemic event, or is it a bleed? So a vascular event, such as a bleed within the brain, potentially.

SPEAKER_02 5:10

Okay, yep, yep. All right, so you're thinking maybe something like a spontaneous subdural hemorrhage. I've seen that before, actually, in a younger man who came in with what looked like a first episode of schizophrenia, paranoid delusion psychosis. Yeah. And it was actually the CT head showed he had a big subdural hemorrhage, which I was really shocked about.

SPEAKER_00 5:27

I've had the same case as an F2. Isn't that strange? Exactly the same. I thought it was schizophrenia, um psychosis, but it wasn't. Um did have a history of schizophrenia in the background, but uh okay, so the next thing I'm thinking about is infection. So infection can commonly cause acute conclusional state. So I'd want to think, ask some infective-like symptoms, any pyrexia, any shortness of breath, cough, any headaches, any urinary symptoms, any gastroentological symptoms? Could this be an encephalitis, a meningitis, or could it be urinary retract infection? Could it be gastroenteritis? So I'd really want to deep dive into all those different signs and symptoms. Trauma.

SPEAKER_02 6:13

So we'd absolutely do a septic screen, but just into it quickly. Don't you think that having a delirium due to an infection, which we do see very, very commonly in older adults, don't you think 63 is a bit young? A fit and well 63 lady who travels the world with no past medical history. Because you've got to have quite a vulnerable brain, don't you, to for like a UTI to give you a delirium? I thought I was quite struck with how young and robust and not much past medical history it'd be unusual for them to suddenly get a UTI, for example, and then go completely delirious with it. I mean, it's it it could happen, but I'm I remember thinking, gosh, the gates are just a bit bit odd for that.

SPEAKER_00 6:50

Yeah, you're right. I mean, it is unusual. I've have seen it, but certainly not as common as I've seen acute confusional states, secondary infection in people who are older in their 80s and 90s. Um, has she had any trauma? Has she had a fall? Is she banged her head? Anything like that?

SPEAKER_02 7:09

Are you thinking of um intracranial bleeds again?

SPEAKER_00 7:12

Yeah.

SPEAKER_02 7:12

Yeah. No, no, nothing like that.

SPEAKER_00 7:15

Okay. Um, so check her blood sugar. It's really simple. Is she diabetic that we don't know about? Have we done a BM on her? Is she hypoglycemic? Is she hyperglycemic? So it's something that we can really think about very simply and identify very much. So they're normal. Normal, okay. Um so is she on any medication? Is she taking anything over the counter that we don't know about? You said amlodipine, but is she taking anything else that maybe could have contributed to it? Any painkillers, any codeine-based products?

SPEAKER_02 7:47

Nothing like that, no.

SPEAKER_00 7:49

Okay. Um I'm thinking about a atrophenic causes, metabolic causes. Um, I'm thinking about neoplastic causes again, very acute. I have seen patients who do have an underlying brain malignancy present acutely with acute confusional state. So I'd certainly want to rule that out by doing a CT scan of the brain, absolutely. Um, but again, it's probably not high on my list of diagnoses at the moment. Um, is there anything that we've done to her, or you know, she, you know, the atriogenic causes that could have contributed to the delirium, unlikely as she's had it for 24 to 48 hours. Um and then medications which we've talked about. Um sorry, I know that's all over the place. I'm trying to gather my thoughts because it is quite a challenging diagnosis, acute confusional state. Is she in pain?

SPEAKER_02 8:55

You gather.

SPEAKER_00 8:56

I know. Is she in pain?

SPEAKER_02 8:57

Uh um, no, but the thing is, it was so challenging because there was a total language barrier with a rather very fraught, understandably fraught, family members translating. And this woman was not well. She was not in a place to be answering questions. In fact, she was trying to barricade herself into the corner of the bay and surround herself by um by uh tables next to the, you know, the bed tables. Um, she was shouting, she was screaming, she was obviously very afraid of something. Um she we couldn't really get sit down and ask her a series of simple questions. Um, the absolute heroicism of the emergency medicine team managed to get some baseline bloods and a CT brain. Uh, I don't know how they managed to do that, but other than that, it was absolutely you know, we couldn't even get her to sit um or to get get into the bed to examine her, let alone sort of ask more delicate questions to delineate a cause of acute delirium.

SPEAKER_00 9:54

Okay. So I guess in this situation then, um I guess you'd go back to basics and you'd do an A to E assessment and try and do an examination of as much as you can. Um, you said that you've done some blood tests, some observations. Let's have a look at those. So if you've got the observations.

SPEAKER_02 10:12

Yes, and I'm afraid they're not very exciting. Well, the blood pressure was 147 over 81. The heart rate was 91 beaks per minute, the saturations were 97% on Roman, respiratory rate was about 22, and her temperature was normal at 36.1.

SPEAKER_00 10:30

Okay, so she's slightly tachinic with a respiratory rate of 22, slightly higher than I'd like it to be. Um so I guess I'd want to look at her. It sounds like it's probably not gonna happen in RT or blood gas, to look at her. Um, is she um blowing off lots and lots of carbon dioxide? Is that why she's uh her respiratory rate's high? But it sounds like that's gonna be quite difficult to get that.

SPEAKER_02 10:54

So yes, we we we got some venous blood, so we got a VBG that we ran off that, so we could see that her lactate is normal, but she wasn't on the venous gas, and of course, you've got to interpret this within that context of being venous, so the COTA will be higher, but it seemed to be about normal.

SPEAKER_00 11:09

Okay, fine. Okay. Um, did you examine the patient? Did you find anything on clinical examination?

SPEAKER_02 11:17

I gave it my best go, Amy, but um it was tough. So she was obscene at the start of very basic examination, observed ambulating independently around the room at quite an agitated pace. There was no obvious um problems with her walking, with her gait, and watching her moving around, I could not see very, very grossly, I couldn't see any sort of impairments of her motor function um at all. Her family tell me that her speech um was actually normal in terms of fluency, and she didn't seem to have any sort of dis expressive dysphasia, word-finding difficulties. Um, she seemed to understand what they were saying to her, but her her thought processes were all over the place. Um, her fixations were very persecutory, that there was um she she was being imprisoned, that somebody was hunting her down, that she didn't recognize a lot of people, she did not agree that she was in a hospital, she did not see that we were doctors and nurses. Um, she'd given us the identity of, I don't know, um, some kind of villains who were holding her down and experimenting on her against her will. Um, all extremely out-of-character stuff. Her family were very upset because they'd never seen their mum, um, their wife ever, ever act like this before. Um, but that was the basis of my examination. Uh, she she didn't seem to have any respiratory symptoms, um, and her family say there was no problems with sort of vomiting or diarrhea, no rashes anywhere. But that was really the limits of my examination.

SPEAKER_00 12:51

Okay. So it sounds like then globally her neurological system is intact, i.e., that she's walking, which suggests that her power in her limbs is normal. Um, and it doesn't say that she favoured one side or the other any weakness. So it sort of goes against this being a big infarct within the brain, doesn't fit that picture. Oh gosh.

SPEAKER_02 13:13

Um And also, how often do you see someone have a stroke, a a cerebral infarctive stroke, and and present with psychosis? I'm sure it could happen, but it if someone will say, oh, well, there's then this case report which but to me, you know, people who have a stroke, they suddenly go paralyzed down one side or they stop talking or something like that. But you don't normally get acute psychosis that the diver I've ever seen, and I can't really explain how that that would work in terms of what area of the brain would they infart for that to happen.

SPEAKER_00 13:40

Did you notice any rashes?

SPEAKER_02 13:42

No, and I had a look. Why are you asking about rashes out of curiosity?

SPEAKER_00 13:47

Um So, I mean, I was saying it's crazy, it's not meningitis, it's not going to be sepsis or meningococcal because she's too well in herself and observations are fine. Are the rashes viral rashes? I'm stretching things now.

SPEAKER_02 14:06

No, I I didn't ever look for a viral reaction because you know you think about organic causes and has she got lots of um has she got lots of cold sores? Could it be her bisymplex cathylitis, that sort of thing? But no, she didn't have any rashes.

SPEAKER_00 14:20

Any purpura?

SPEAKER_02 14:22

No.

SPEAKER_00 14:23

So I was thinking thrombotic thrombocytopenic purpura can present with confusion.

SPEAKER_01 14:28

Okay, yeah, yeah.

SPEAKER_00 14:29

I mean that's again that's quite um uh any other rash. No, I think that's anything anything else you were thinking of from a rash perspective?

SPEAKER_02 14:46

No, that was about it really. I mean, if if she hit had an infection, then maybe that would manifest as a sort of dermatological eruption of some description. But no, and I was looking quite hard for infection. As I say, yeah, she was apebrile, her blood test results. She had a CRP of four, which is normal, her white cells were normal at 9.1, her neutrophils were normal, um, HB and platelets are both normal. And looking at her Us and E's, um, sodium was 139, potassium 4.7, that's both normal range, urea was 3.1, creatinine was 63, that's normal range as well. So the bloods were absolutely completely bland.

SPEAKER_00 15:21

Did you do a thyroid function test?

SPEAKER_02 15:24

Um, not at that point, but I did all put it on later. Okay. Yeah. So, and it did actually return as normal eventually, but that's a good thought. Um, so what are you thinking about there?

SPEAKER_00 15:35

I was just thinking of um hyper or hypothyroidism. Um, if it's really severe, can present with um elements of confusion. So I'd really want to ensure that she has neither of those.

SPEAKER_02 15:51

I remember being as at med school, I was taught about a really harrowing case of a woman who had severe myxedema because of severe hy malignant hypothyroidism, um, who eventually develops a mixedemic coma and how they described how she she completely became um delirious, was undressing, was breaking things at home, became colder and colder and colder. I've never seen it in my own practice, but it is something I always worry about and I always try to.

SPEAKER_00 16:14

Yeah, absolutely.

SPEAKER_02 16:17

So if I tell you where I was at. Yes, please. Yeah. So I was like, this woman is not well. She's either having an acute delirium due to an insult, which we mentioned, you can run through the PINCHME acronym to do all the different causes of delirium. Um, potentially, it was acute onset. Um, but going against delirium, I just feel like you've got to have, as I said before, it's usually people who have got vulnerable brains who get a get a delirium. So when they get um an insult, such as a severe infection or a metabolic disturbance, they uh it can present as acute confusion. And she just seemed too young and too robust for that. And also, I have you do see a delirium presenting as acute psychosis, but um a hyperactive delirium, but most of the time, a hyperactive delirium, it just has a slightly different flavor to me. It tends to be disorientation and emotional dysregulation, the day-night sleep reversal. Um, and uh to me, it just didn't smell right with the delirium that I see on a day-by-day basis. So delirium is one option. The other option I had was: is this pure psychiatry? Is this a first presentation of an acute psychotic episode? It looked psychotic, and I I absolutely admit I'm not a psychiatrist, but all of these um delusions of persecution, the paranoid aspect to it, someone's out to get me, the very florid nature of it, all these very odd ideas. Um uh she yeah, family were saying she she thinks we're not real, and that's that's that's derealisation, isn't it? Which you do see the psychiatric diagnoses. Um but then I thought, why on earth would a 63-year-old woman get a you know, a first psychotic episode or de novo for no reason? You know, usually your first presentation of psychosis is much younger in your 20s to 40s, whether it's uh an acute manic episode or a first uh presentation of schizophrenia, you get you get it out of the way quite early in life. So I thought that was odd. And so did the cycliaison team, and that's why they were saying, look, we don't make this diagnosis of psychiatric, a primary psychiatric until we've made sure it's not organic. So we get to organic. What could be uh an organic physical mental problem, which uh physical problem, which is causing this, this, this presentation? Um, the one I always think about is is encephalitis, viral encephalitis. So has she developed an acute infection um which has moved to this central nervous system and it's caused inflammation of the brain? Um, a less, much less common, a very rare diagnosis, but I do see it every very now and again, which is um autoimmune encephalitis. And you do see that in older people, and that can be um due to autoimmunity, or it could be perineoplastic. So if they have a malignancy um diagnosed, undiagnosed elsewhere, they can get a perineoplastic um encephalitis due to that. So those are my two big organic ones. I've had the CT head in AE, so I know that she hasn't had a big subdural hemorrhage, which is the other one I was thinking about, an intracranial nastiness. And the other organic things I think about is severe electrolyte disturbances and hypoglycemia, like you mentioned, and I managed to take those all off the table as well. So here we are. So is it psychosis? Is it organic or is it a delirium? And now I've got to do some tests to work it out. Um, and this is a this is a something that happens in acute medicine relatively frequently. You're tasked with getting some pretty important but pretty complex test results to look for organic disease, um, and then the logistical challenge of doing it on someone who is really confused and will not, cannot um comply with any of these tests that you want to do. Um so tests. What should you want me to do in this situation?

SPEAKER_00 20:10

So gosh, this is a this is a real difficult one, I have to say. So you mentioned the pinch meme monic for causes of delirium. So just gonna recap on that. Um P is for pain, eye to infection, N is nutrition, C is constipation, H is hydration, M is medication, and E is environment. Could this all be environmental change?

SPEAKER_02 20:34

What do you mean?

SPEAKER_00 20:35

Well, she's traveled from Japan, she's been traveling in France and then Europe, then the UK. It's a big change. There's a lot of travel going on there. Um, I mean, when I if I was to travel that much, I'd probably feel a little bit disorientated, but probably not that much. So that's just something that's in my background. I don't know. Um so what tests am I going to do?

SPEAKER_02 21:02

So we mentioned enkephalitis as a potential, and the the standard tests we do for those is obviously a lumbar puncture and an MOI. Now, I don't know if any of our listeners out there have ever tried to do a lumbapuncture or an MRI scan on someone who is literally trying to, you know, barricade themselves into a corner of the room, is absolutely petrified out of their wits and believes you are some kind of torturer who's come to kill them or persecute them. Yeah. But literally, absolutely and nightmare to do safely. Now, you might say, well, just give them a bit of sedation and that and do it. But sedation is a tricky thing. There's a whole branch of medicine dedicated to safe sedation. We call them an ethetist, that's not their only job, obviously. They do many other important things, but we can't just bung someone um some uh benzos and wait for them to get sleepy, then send them down to the scanner or roll them over and do a lumbar puncture on board. Because, first of all, how are we going to administer those? Benzos. We can offer them orally and maybe they'll take them, but there's a very unpredictable onset and offset, and you don't really know how well they're going to metabolise and react to that. So offering someone, say, five milligrams of Valium or a milligram of Lurazepan is really a roulette wheel about what you're going to get out of that. And when you have got a MRI slot at 2 pm this afternoon, um, you getting the timings right, so they're just flat enough to have the scan, but um still able to get in and out of the scanner, it's just it's it's impossible, really. And then do you say, well, well, why don't we give them something like a bit of IV Laraz or IV medazolam? At least that will sedate them well enough to uh do the lumber punch or do the MRI scan. And um I'll say here and now, giving someone IV sedation, IV benzos, and then sending them away with a porter in a lift to um the radiology department, which is an outpatient department, to lie around, wait for their turn, then go on M and come back is an absolute recipe for disaster and a very unsafe treatment for your patient. They are unfasted, they could easily vomit, they could aspirate, they could lose their airway, they could develop respiratory depression, the effect could be too strong and they might need some oxygen support, it could not be strong enough and they become psychotic and try to throttle the porter and the lift, but it's it's very, very, very unsafe. Um, and I have had people suggest in the past should we just give them some sedation and send them for the scan, at least it's done. Um, and even saying, Oh, I'll go with them as an escort, but what are you gonna do if they lose their airway in the corridor? I uh you know, you're gonna take an airway bag with you. Well, you it's just really, really ropey. Similarly, giving someone sedation on the wall so you can roll them over and do an LP with a bit of oxygen on, okay, it just makes me anxious. I find that's quite a risky way to do things. So, very often when you want to get a lumbar puncture and an MRI for these patients, you're really liaising with your anesthetic colleagues who are on call and have hundreds of competing um other duties to do. So, trying to get an available anesthetic colleague to give safe sedation airway management, who is available to do so at the exact same time their MRI slot comes up, or the rest of the team is ready to do a lumbar puncture, is rarer than hens teeth. I've never cracked that one. It's just not doable within the constraints of the NHS and how it functions. So, what you end up doing if you really want these tests? A G A MRI and a GA lumbar puncture. Again, not for the week trying to organize these two tests. Because if the anetists say, I'd like to facilitate, we do this on our C pod list. Please come down at 7am in the morning to put them on the C pod list and discuss with the team. But even more emergent case comes in, they'll fall off that list and we'll have to do a 7am thing the next morning. It it just it eventually, in my experience, just does not happen. Um, or the person who's meant to go down at 7 a.m. to discuss with these people gets caught to a cardiac arrest or they can't leave the ward. Um, and the third option is sometimes I say, we can do it on a GA guided MRI list. If you do them on a Tuesday, we'll do it next Tuesday, which is great if it's Monday evening, but if it's Wednesday morning, then do you wait a week for this patient to have your test? Right, that's me talking a lot. And there's a lot of experience uh coming up there. But I just to I really wanted to emphasize getting these really crucial tests to use to rule in or rule out organic disease for these patients who present with their first psychosis are logistically as close to challenging as as as can be.

SPEAKER_00 25:41

So I'm gonna say something really controversial.

SPEAKER_02 25:44

Go for it.

SPEAKER_00 25:46

Do we have to do any tests?

SPEAKER_02 25:48

Well, we don't do anything we don't want to do, but when there's a no, Amy, we'll never know the diagnosis, no?

SPEAKER_00 25:55

So what I'm just thinking, um, number one, I really want to understand what the family think. I know you said that they're quite obviously they're quite distressed, but you know, really sit the family down in the family room and just get to the bottom of things and just say what's going on, is anything going on at home? What's been going on in your travels? How was she in Paris? You know, and really get really take a thorough history from the family as much as you can. Say, what you know, what do you think is going on with your mom or your partner? That can help sometimes. Do nothing is always an option and watch and wait. You know, with delirium, we know that, or conf confusion, we know that Amy, where she is, is a very loud, very scary place. So the management of delirium, acute confusion state, primarily is put in a calm environment with good lighting, with people around you who you know, maybe um with your family in there to try and calm things down a little bit. So takeaway from the chaos of the emergency department can be helpful. So that's a possibility. Like you, I'm not a big fan of um using sedation um as a as a treatment because I think that's more therapeutic for us. However, if she was a danger to herself or a danger to others around her, then that's when we may need to utilize some sort of sedation or some sort of mild antipsychotic, which you very rarely use in um delirium if needed. So overall, when I get a case like this, I write in the notes. Do you know what I've discovered last week as well? How to dictate my notes on a dictaphone and it types it directly onto the electronic patient record, which has literally changed my working day, but it does mean my notes now are like an essay.

SPEAKER_02 28:00

But um that does always a scream of consciousness, horrible insight into into Amy's psychosis, psych uh uh subconscious. We can do that, but I find it makes all the spelling mistakes. It can't spell medical terms.

SPEAKER_00 28:12

Oh no, it does, it can.

SPEAKER_02 28:14

Oh, maybe I need a new software package. If I said things like, you know, encephalytic or or or a lumber punch or something, it would be spelling all sorts of disaster.

SPEAKER_00 28:22

Oh no, it's so what I would do now is I would do problem representation. I have a 63-year-old female who is a background history of hypertension, who takes amlodipine, who is fit and well, who's traveling from Japan, who presents with confusion, agitation, paranoid thoughts. Her observations are normal, her investigations are normal, her CT bed is normal. The most serious diagnosis I need to exclude here is a bleed on the brain, which I've excluded. I need to exclude an infection, such as encaphylitis meningitis. I can't exclude that without an LP, but her CRP is normal, white cells normal, neutrophil is normal. I would have expected those to be abnormal if there was an infection. I'm going down my list of seriousness of causes. Um, could this be seizure activity? Potentially.

SPEAKER_02 29:24

Oh, that's a good one. Yeah. Yeah, oh, that's a good one actually. And I forgot to mention that's a really good test to do for um when you're thinking about organic stuff, is are you having subclinical seizures? So doing an EEG as well as hey, and an EEG is no easier than a lumbar puncture and MOI if someone's floridly psychotic, but that's a really good addition to the to the screen.

SPEAKER_00 29:42

Yeah, so that's something that you can think about. Um, is like is a subclinical seizure activity, which can present like this. And subclinical seizure activity can also be a sign, I've seen it, of ultimate cathalitis. So that may fit that again, very rapid onset. Um we've looked at her sugar, calcium levels, sodium, potassium, magnesium, B12, folate, thyroid. I mean, down the bottom of the causes is could this be all environmental? Very busy, very exhausted, lots of travel, calm side room, allow her to sleep and watch and wait.

SPEAKER_02 30:26

Do you know what, Amy? I I I really, really agree with that. And I I said, and I had a you know, one of my fantastic FY1s saying, I've been trying, I've been on the phone, I've tried with the MRI and and I need this. And I said, Do you know what? Let's just park it for now. Um let her family think she's calmed down a bit. Let's see what things are like in the morning. She's in a safe place, she's on the ward, she's in hospital. Um if you know, if your suspicion is strong about enkephalitis, you can empirically start them on a cyclovier whilst you're getting things ready. Cyclovia is used pretty safe. It sometimes it causes an AKI, um, so you have to keep an eye on their renal function, but most people you can start it empirically whilst you're trying to get your ducks in a row. And um, and let's see. And I mean we came in the next day, and a family said she's a little bit more settled. She seems to know she's in hospital now. We want to take her home. We've booked her flight to Japan this Friday. We've got to get her out of here. We think the hospital's making her worse. We really think she ought to go home. Um, and she's starting to improve. And then you got a little thought in your head about hmm, is this a safe discharge? The patient doesn't have capacity to self-discharge herself. Can I can I let the family do it? And the family were not being obstructive or confrontational anyway. They were saying, please can we take her home? We think this is the best way forward, and she was starting to improve. And that's when I had a little idea. Um, it was an idea based on a diagnosis I remember reading about, probably at med school or when I was a very young doctor, which I've never made before. But I rang up the psychiatry, the liaison psychiatry team again, and said, We haven't done the MRI, the EEG of the lumbar puncture. The patient seems to be improving now, and some of the psychosis seems to be melting away. In fact, she's now sitting there eating in her bed space, looking quite calm. Um I noticed that she came from Japan to Paris, then Paris to us two days ago. It might be unlikely, but could she have Paris syndrome? Have you ever heard of it?

SPEAKER_00 32:26

No, I've never heard of syndrome.

SPEAKER_02 32:28

So I was showing off I was showing off a little bit to the to the FY1 I was working with.

SPEAKER_00 32:33

Have you made this up?

SPEAKER_02 32:35

No. And I said, you know what? And I said when I was reading her itinerary and it went, is it a Paris syndrome? I went, Oh, I've heard of this before. I wonder if she's got Paris syndrome. I'm not brave enough to make that diagnosis, but if we can get the Lears Psychiatry to come back and ask them that question, um, you know, I'll I'll dine out on this for the rest of my career. Um, and the Leah's and the Lia's psychiatry consultant actually came to see her and they came and found me in the office afterwards. Went, oh, I've seen um I've seen this lady, and I said to him, Oh, brilliant. Well, we think she's got Paris syndrome. And he said, Oh, yes, she does. And I'm gonna tell you about Paris syndrome now. Please stick. It's so funny, and I never thought I would make this diagnosis in my life because it almost seems fictional. But Paris syndrome is a form of acute delusional state, mostly experienced by people visitors from Japan when they come to the West. Um, and it's thought to be a severe, extreme form of culture shock. And it isn't necessarily Japanese people coming just to Paris, but that's how it was first described in these people. But it can be anyone coming from one culture to another who then develops some very, very strange psychiatric symptoms. Um, and it's it's classically, as I say, described with Japanese visitors to Paris. And the symptoms are acute confusional state, delusional states, feelings of persecution, feelings of derealization and depersonalization. It's always transient and it always improves. And as you said before, it would be the environmental cause. Um and the causes of it, it's meant to be, and and I'm not a I'm not going to offend anyone from the beautiful city of light from Paris, but it's meant to be a form of extreme disappointment when visitors come and they find, and this is the index case in Paris, it's not what they thought it would be. Um, because sometimes these European West Western cities are very idealized and romanticized in other cultures. They come here, experience profound jet lag, exhaustion, months and months of planning the trip, um, a very heightened sense of expectancy, and they come to visit a city, say Paris, and they find, oh, it's just an ordinary city. It's just people. There's rubbish on the streets, there's workers on the metro, it's just ordinary folk. Um, it's raining. Um, the culture's different. People don't treat people like in shops and in places as they do where I'm used to. I don't speak a word of the language. I feel very isolated. I don't understand how to order in restaurants, I don't understand what the system is in the supermarket. Um, and the cause of uh um the cause I meant to be cultural differences, idealization of Paris, and it does not live up to expectations, exhaustion, jet lag, and the language barrier. And it's actually a very well-described symptom which has been described. And it can be any city, could be London, could be Rome, anywhere where there's a high sense of romance and people coming from a very different culture. Oh, Wolverhampton, I think this. Sorry, yes, but even Wolverhampton. I'm sure it's very, very romanticized in Japanese culture. Um, but I thought that was absolutely fascinating. And I remember reading about it thinking, it doesn't so it doesn't sound real, it sounds like made up to me, but it absolutely is real. And the timeline was perfect as well. 24 to 48 hours after visiting Paris, um, with in the in the cases that you read online, when they start to develop these very, very odd symptoms, it always improves and they have to just go home and with what my patient did eventually.

SPEAKER_00 36:14

Wow. Wow.

SPEAKER_02 36:16

And do you want to know something very interesting? I was doing some research about Paris syndrome. There's an opposite. There's an opposite called Florence syndrome, where people visit Florence and they can experience um acute confusional states due to um how beautiful it is, due to be overwhelmed by the beauty and the romance and the um how gorgeous everything is, and it's more than they expected. And I thought, we went to Florence earlier this year. We did a podcast episode from European Federation and conference in Florence, but neither of us got Florence syndrome. But it was beautiful, but it was very, very beautiful. But there you go. So an ultimate diagnosis of Paris, and she didn't need those tests eventually. She didn't get the lumbar puncture, she didn't get the MRI. She felt well enough to go back to her hotel room and her family took her on a plane and took her back to Japan. Now I have no follow-up for this patient because obviously she's gone far away. But I thought it was a really interesting case because it talks about the difficulties of getting tests that are actually important at the point of ordering them. Uh and sometimes, sometimes doing nothing as you say, and sort of saying, let's just see what happens here. There's no rush, they're in a safe space. Yeah. We just need to, we uh and it's worth mentioning we have another 20, 30 patients we got to see today. We have to balance our time. Of course. We can't spend a whole day trying to um organise these cases, and uh, we we have to see our other patients as well. What's the overall safest thing to do here that's that's that's just by everybody? And um, and then I thought Paris syndrome is a nice little button to put on it, and maybe that's something people will remember now if they ever see it.

SPEAKER_00 37:50

Absolutely. Thank you so much. So many learning points from there. Number one, Paris syndrome, number two, Florence syndrome. Number three, I think the beauty of this case is in the simplicity, in the way that sometimes watching and waiting is the best course of action. Is the best investigation is to watch and the best treatment is to wait. Now I'm, you know, me, I'm very pro watching and waiting and not doing many tests, which some people like, some people don't like. But again, I think in this case, you know, if we'd done lots of investigations, it could have made her feel a little bit worse actually, and contributed to the anxiety and the stress that she was undergoing. Thank you, Ben. Brilliant as ever.

SPEAKER_02 38:39

Thank you.

SPEAKER_00 38:41

So our first episode at the Royal College of Physicians of Edinburgh. Thank you, Ben. I think that was a great episode to start with. And for all of you listeners out there, new ones and old ones, you will still be able to get us on all of your usual channels. Please rate to view and subscribe to the podcast, and we'll be back soon. Thanks for listening.