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[Dementia in patients of Hospital das Clínicas da UNICAMP].
OBJECTIVE: To report the relative frequencies of the causes of dementia in patients seen at UNICAMP Hospital. METHOD: From 1989 to 1998, 261 dementia patients were admitted (89.7% studied retrospectively, and 10.3%, prospectively); mean age 63.5 years (+/-13.2), and education 3.6 years +/- 3.9; 25% illiterate). Diagnosis of dementia and its subtypes was based on DSM-IV criteria, CAMDEX, NINCDS-ADRDA, NINDS AIREN/ADDTC, Lund-Manchester, besides tap-test, including laboratory and neuroimaging examinations. RESULTS: Sixty five patients (24.9%) had vascular dementia, 62 ( 23.7%) Alzheimer's, 29 (11.1%) depressive pseudodementia, 28 (10.9%) normal pressure hydrocephalus, 14(5.4%) mixed, 12 (4.6%) post-traumatic, 9 (3.4%) frontotemporal and 38 (14.5%) had diverse or unknown causes. Dementia was minimal or mild in 123 (47.1%), moderate in 95 (36.4%), and severe in 43 (16.5%). CONCLUSION: Frequency of vascular dementia was 24.9%, Alzheimer's 23.7%, and normal pressure hydrocephalus 10.7%, in disagreement with that found in the neurological literature (20-30%, 50%, and 1-4%, respectively), probably because we are dealing with cases admitted to a tertiary university hospital. Epidemiological studies are needed to disclose the true proportion of these dementia syndromes in the population.
Episodic factitious gingival injury secondary to topical anesthesia. A case report.
The contribution of topical anesthesia to the incidence of severe factitious gingival injury in an adult patient is reported. A brief review of the literature is also presented.
Factitious apraxia.
A case is described in which a patient had pseudoneurological symptoms that were present only upon direct observation or when the patient was in clinical test situations. The differential diagnosis of apraxia is discussed as well as clinical suggestions for evaluating patients with suspected factitious apraxia.
Self-induced abscesses: a diagnostic and treatment enigma.
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A case of factitious aplastic anemia.
OBJECTIVE: We report the case of factitiously induced aplastic anemia by the ingestion of busulfan, a bifunctional alkylating chemotherapeutic agent used in the treatment of chronic myelogenous leukemia. The medical consequences and financial costs of this illness are reported. The reader will gain an understanding of the relevant clues to the diagnosis of a factitious hematologic illness, the psychodynamic issues present in this case and the legal, ethical and countertransferential issues raised by the case. METHOD: A single case review including medical and billing records, patient and staff interviews and literature review. RESULTS: The covert ingestion of busulfan by this patient resulted in life-threatening bone marrow suppression, bilateral aseptic hip necrosis, transfusion-dependent thrombocytopenia and a chronic pain syndrome. Her treatment was complicated by noncompliance with prescribed treatments and polymicrobial sepsis possibly secondary to the self-injection of feces into her central line. To date, the total cost of care for the treatment of this patient's medical complications secondary to her ingestion of busulfan exceeds $1,100,000.00. CONCLUSIONS: This case underscores the importance of the early recognition by the primary care physician of the possibility of a factitious etiology of hematologic abnormalities such as aplastic anemia due to the ingestion of bone marrow ablative medications. The index of suspicion is increased when the patient is a young health care provider, usually female, with atypical pancytopenia and an unusual disease course and response to treatment.
Depression, dementia, and social supports.
Recent literature on the relationships among dementia, depression, and social support was reviewed, with particular emphasis on the diagnostic differentiation of dementia and depression, and the role of these three entities in elderly individuals with cognitive impairment. Dementia-like symptoms arising in depression and the coexistence of dementia and depression are discussed. Research is necessary to determine more objective criteria for depression and dementia, to provide cognitive and psychiatric testing for elderly individuals, to clarify the diagnostic or prognostic value of the term pseudodementia, and to further elucidate relationships between depression, dementia, and social support.
Feigned adverse drug reaction to radiographic contrast material.
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Factitious hypoglycemia mimicking insulinoma.
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C-peptide in factitious hypoglycemia from sulfonylurea.
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A new technique for the assessment and modification of feigned memory deficit.
The two-alternative forced-choice technique has been successful in the assessment of functional sensory deficits because it has the power to assess deception or exaggeration. This report describes how the procedure can be used for the assessment and modification of a memory complaint. Three case studies are presented. In two cases the supposed deficit was judged to be functional. In a third case a brain-injured patient "cheated" to obtain correct answers, suggesting that he was trying to hide a deficit and not attempting to obtain compensation.
"Faking bad" on the MMPI, MMPI-2, and Millon-II.
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Pseudodementia or Ganser syndrome in a ten year old boy.
A case of pseudodementia, occurring in a 10 year old boy following a minor head injury and associated with a claim for compensation, is presented. The case is unusual in the age of the patient and the failure to respond to treatment including prolonged hospitalization. The case is discussed in the light of the available literature and an attempt is made to clarify the confusion surrounding the terms pseudodementia and Ganser Syndrome.
Use of an amytal interview in the management of factitious deaf mutism.
We describe the case of a young woman presenting with deaf mutism and self-damaging behaviour. We emphasize the active investigation of psychological and physical symptoms, combined with gradual and gentle confrontation in a supportive setting.
Ganser syndrome in a 10 year old boy--an 8 year follow up.
A case of pseudodementia in a 10 year old boy was first reported in 1981. When reviewed 8 years after initial presentation, his symptoms were largely unchanged. The case continues to be complicated by claims for compensation and a successful appeal against the initial compensation judgment.
The Simulation Index: a reliability study.
The Simulation Index was derived from 15 error types on the WAIS-R and WMS occurring with a high degree of specificity in a criterion simulation group (n = 16) and a further five error types specific to a group of patients sustaining severe head injury (n = 16). The reliability of the scoring criteria was evaluated in terms of the rate of agreement in scoring for the presence or absence in each of the 20 error types achieved by two independent neuropsychologists. Percentage agreement rates for each of the 20 error types ranged between 83 and 100%. When identification of group membership was attempted on the basis of simple inspection of the test protocols, diagnostic hit rates were at chance level. When identification of group membership was based on Simulation Index cut-off scores, each of the raters achieved a diagnostic hit rate of 94% for each of the simulation and head-injury group patients. The results support the reliability and clinical utility of the Simulation Index.
A case of thyroid storm due to thyrotoxicosis factitia.
We describe a case of thyroid storm due to thyrotoxicosis factitia, which was caused by the ingestion of excessive quantities of exogenous thyroid hormone for the purpose of reducing weight. An 18-year-old female was admitted to the hospital 24 hours after taking up to 50 tablets of synthyroid (1 tablet of synthyroid : levothyroxine 100 microg). Because of her stuporous mental state and acute respiratory failure, she was intubated and treated in the intensive care unit. After reviewing her history carefully and examining plasma thyroid hormone levels, we diagnosed this case as a thyroid storm due to thyrotoxicosis factitia. Her thyroid function test revealed that T3 was 305 ng/dL, T4 was 24.9 microg/dl, FT4 was 7.7 ng/dL, TSH was 0.05 micro IU/mL and TBG was 12.84 microg/mL (normal range: 11.3 - 28.9). TSH receptor antibody, antimicrosomal antibody, and antithyroglobulin antibody were negative. She was recovered by treatment, namely, steroid and propranolol, and was discharged 8 days after admission. Thyroid storm due to thyrotoxicosis factitia caused by the ingestion of excessive thyroid hormone is rarely reported worldwide. Therefore, we now report a case of thyroid storm that resulted from thyrotoxicosis factitia caused by the ingestion of a massive amount of thyroid hormone over a period of 6 months.