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Case records of the Massachusetts General Hospital. Case 26-2008. A 26-year-old woman with headache and behavioral changes.

Dr. Thomas J. Cummings, Jr. (Psychiatry): A 26-year-old woman was admitted to this hospital because of headache, behavioral changes, abnormal movements, and inability to communicate. The patient had been well, except for occasional migraine headaches, until 7 weeks earlier, when generalized, diffuse headache developed. It was most severe in the occipital region, with associated neck stiffness, sensitivity to sounds, intermittent blurred vision, nausea, and vomiting. There were no prodromal symptoms or visual scotoma, which had occurred routinely with her migraines, and the pain did not diminish in response to her usual migraine treatment. During the next 10 days, she was seen multiple times in the emergency departments of other hospitals. A computed tomographic (CT) scan of the brain obtained without the administration of gadolinium reportedly showed inflammatory changes in the left maxillary and ethmoid sinuses but was otherwise normal. Medications, including butalbital, oxycodone, hydrocodone, ibuprofen, sumatriptan, indomethacin, acetaminophen, and caffeine, were administered, with transient partial relief from pain. Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of depersonalization developed. Five and a half weeks before admission to this hospital, increasing visual disturbances that were thought to be visual hallucinations developed, with increasing confusion. On evaluation in a local emergency department, laboratory tests revealed negative results in tests for Lyme disease and syphilis. She was admitted to an inpatient psychiatric facility. The patient had a history of migraine headaches, obesity, asthma, and seasonal allergies. She smoked cigarettes and drank up to six alcoholic beverages on weekends. Several days before the onset of symptoms, she had attended a party and taken a drug that was reported to contain cocaine, crystal methamphetamine, ecstasy, and possibly salvia. On admission to the psychiatric hospital, her speech was initially fluent and appropriate but became garbled and incoherent; abnormal movements developed, including hyperextension of the arms and movements of the mouth. Antipsychotic medications, including haloperidol, risperidone, benztropine, lorazepam, olanzapine, valproic acid, and quetiapine, were administered, without improvement. Fever developed, and the serum level of creatine kinase was reportedly elevated. On the fifth day, she was transferred to another hospital because of suspected neuroleptic malignant syndrome. Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes