Autoimmune encephalitis may manifest as a typical limbic syndrome or with isolated syndromes such as atypical psychosis or refractory epilepsy. Psychotic, affective and behavioral disorders are frequently seen especially in Nmethyl-D-aspartate receptor (NMDAR) encephalitis putting autoimmunity to forefront as a potential cause of some psychiatric disorders [1,2]. Studies showing the relationship between cell surface antigens and first-episode schizophrenia or atypical psychosis have fueled interest to this hypothesis [2]. Moreover, post-herpes simplex virus (HSV) and post-varicella zoster virus (VZV) encephalitis with NMDAR antibody and remarkable response to immunotherapy have also been defined [3,4]. In parallel with these studies, we herein report a case presenting with psychosis attacks following systemic VZV infection and improving after immunotherapy.A 17-year-old male with no medical history of prior psychiatric problems was admitted by his family with sleeping difficulties, altered personality, aggression and self-talking. Four weeks ago, he was diagnosed with chickenpox based on typical skin rashes in the form of small blisters all over his body. About 7 days later, while his skin lesions were regressing, he started self-talking, having auditory and visual hallucinations and displaying violent behaviors. His psychomotor activity was increased, he was irritable and anxious. His judgement and insight were deteriorated and attention, impulse control and frustration tolerance were decreased. Neurological examination did not show any focal pathological findings. Routine blood and urine studies and cranial MRI performed upon admission were normal. EEG showed diffuse mild slowing with no epileptic discharges. CSF examination revealed no lymphocytes, normal protein and glucose levels. CSF PCR assays for viral pathogens (VZV, HSV1/2, CMV, HHV-6, enterovirus and EBV), CSF cultures for bacterial (including tuberculosis) and fungal pathogens and extensive panel for rheumatological-vasculitic disorders were negative. Serum VZV IgG was positive compatible with the chickenpox history. Serum and CSF samples were negative for antibodies against Hu, Yo, Ri, Ma2, CV2, amphiphysin, NMDAR, a-amino-hydroxy-methyl-isoxazolepropionic acid (AMPA) receptor, contactin-associated protein-like 2 (CASPR2), leucine-rich, glioma inactivated 1 (LGI1), gamma-amino butyric acid (GABA) B receptor and glutamic acid decarboxylase (GAD). Radioimmunoassays for detection of serum voltage-gated potassium channel complex (VGKC) and voltage-gated calcium channel (VGCC) antibodies were also negative. The patient gave no response to optimal dose of mood stabilizers and antipsychotic drugs. These medications did not cause any side effects (e.g., movement disorders), as well, however, the patient developed analgesic-resistant throbbing headache. Due to absence of evidence for any metabolic, toxic and & Erdem Tüzün
Early diagnosis of autism certainly stands as one of the most important determinants to ensure a better prognosis of the disorder, it is common that the screening programs to ensure this, end up not being implemented in health systems of many countries. This may stem from the disadvantages of classically suggested scale‐based screening (SBS) programs. This study presents a nationwide recognition and referral model for early diagnosis of autism spectrum disorders (ASD), in order to meet the obvious need for new methods. The model consists of interactive video‐based training (IVBAT) of health care workers (HCW), a system where family physicians (FPs) record five probable indicators of autism in their family medicine information system; and is therefore, a practical referral system in which the FP may refer a child with any suggestive finding to a child psychiatrist and may well continue to monitor recently diagnosed cases. The autism teams consist of trained child psychiatrists and coordinators, who delivered trainings to 29,612 FPs and 23,511 nurses countrywide. Of 98.8% FPs were trained throughout the country. Total of 1,863,096 children were reported to have a brief examination of autism signs in Family Medicine Units by trained FPs and nurses. A total of 55,314 (2.96%) these children were deemed at risk for ASD and were referred to child psychiatrists. In the evaluation of 55,314 children by child psychiatrists, 10,087 cases were diagnosed with developmental disorders, while 3226 of children at risk were diagnosed with autism. The results of this study, which reached to the largest sample to date, suggest that some other alternative methods, in addition to SBS should also be tested in order to screen ASD. Lay Summary In this study, a nationwide recognition and referral model for early identification of autism spectrum disorders (ASD) is presented. Scale‐based screening (SBS) is the most recommended model for autism, however, it is clear that most countries can not implement this model in their health system. The results of this study, which reached to the largest sample to date, suggest that SBS may not be the only me for screening ASD and that alternative methods should be tried, as there is an obvious need for exploratory approaches.
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