In this issue of the Cleveland Clinic Journal of Medicine, Prayson and Franco paint a comprehensive picture of the key medical and therapeutic issues faced by patients with Asperger syndrome.¹ They offer a refreshing optimism about contemporary treatments aimed at enhancing independence and quality of life, while being realistic about the challenges for these patients, such as making the transition from pediatric care to adult care. Importantly, their overview offers practical suggestions for improving medical care through a greater understanding of the syndrome, along with strategies for how to relate to patients who have a difficult interpersonal style.

See related article

In this editorial, I focus on lessons learned in our practice that help identify the problems that people with Asperger syndrome have, and I build on the advice of Prayson and Franco on how to improve patient experiences in the adult medical setting, particularly by diminishing confusion and uncertainty in doctor-patient interactions and by supporting ongoing functioning.

PEOPLE WITH ASPERGER SYNDROME HAVE ALWAYS LIVED AMONG US

Asperger syndrome is being diagnosed more frequently, using criteria recognized by a greater number of professionals. This diagnostic distinction offers a clearer understanding of a group of people who have always lived among us—often standing out because of their appearance, behavior, and communication style, even before a common label existed for their condition.

In less-informed communities, they might be described by neighbors or peers as eccentric or odd, even when they present no obvious dysmorphic or other distinguishing physical features. In fact, some may stand out more because of their accomplishments. The behaviors reported for some innovative scientists (Einstein), inventors (Ford, Edison), musicians (Beethoven), and others might lead to a diagnosis of Asperger syndrome today, while an obsessive nature also characteristic of Asperger syndrome might well have enabled them to think and create in astonishing ways.

As we have come to understand this syndrome better, we have recognized that it is a spectrum. Some patients are highly functioning, for example, and different patients have different needs.

Steve Silberman,² writing for Wired magazine, coined the term “geek syndrome” and suggested that geeks marrying geeks may help account for the comparatively high prevalence of autism and Asperger syndrome in “techheavy” communities such as Silicon Valley in California and Route 128 in Massachusetts. “At clinics and schools in the Valley, the observation that most parents of autistic kids are engineers and programmers who themselves display autistic behavior is not news.”² Temple Grandin, arguably the best-known person with an autism spectrum condition, has characterized the NASA Space Center in Houston, TX, as a similar community.

Given this correlation, it follows that colleges and universities offering engineering, computer science, and other technical programs or degrees should have a relatively high prevalence of students with Asperger syndrome. The Massachusetts Institute of Technology, where such a pattern is often observed, offers a course entitled “Charm School,” and its online course description is suggestive of the unique needs of this population³:

“How do I ask for a date? Which bread plate is mine? At what point in a job interview can I ask about salary? Should I use a cell phone while on the T or the elevator? How can a student network to find the perfect position? Join us for MIT's 19th Annual Charm School to find out these answers and more.”

COMMUNICATION DISTURBANCES

The challenges a person with Asperger syndrome may be experiencing are often very difficult to understand. While these people may look normal and demonstrate average to above-average intellectual functioning, their sometimes-peculiar behaviors and deficits in social skills are often difficult for peers to interpret— and to forgive. People with Asperger syndrome want to get along with peers, develop relationships, and succeed in the workplace, and they feel perplexed that others sometimes seem put off by their behavior.

At the core of this discomfort are a range of communication disorders that negatively affect interactions with others. One practical indication of a communication disorder is whether more attention is paid to how something is said than what is being said. This may present to the physician in different ways.

Language

Difficulty with introspection and description may render a patient incapable of describing symptoms and related historical information. In addition, the idiomatic and figurative nature of English may lead Asperger syndrome patients to misunderstand what the physician is saying—even common nonliteral expressions such as “Hop up on the table,” “You’re as fit as a fiddle,” “Are you feeling under the weather?” and “I’m all ears.”

Speech and voice

For the person with Asperger syndrome, speech is often marked by prosodic disturbances, including problems with varying and atypical intonation and stress and, less commonly, unusual fluency patterns and residual articulation issues (l, r, and s sounds). These characteristics can be addressed in therapy.

Conversational style

When people with Asperger syndrome engage in conversation, it is usually brief, or they tend to monopolize it with topics of high interest to themselves or topics of a perseverative or obsessive nature. The patient also tends to have limited perspective and experiences difficulty with higher-order language (including inference and reasoning).

Nonverbal language

A host of nonverbal communication problems include the use of unacceptable social distance and the unintentional messages conveyed nonverbally by unusual clothing choices and poor grooming and hygiene.

WHAT CAN BE DONE IN THE OFFICE VISIT

The key to a successful visit with such patients is to help them anticipate and make sense of their experience. In the visit, predictability should be emphasized and “chaos” avoided. Try to schedule the patient with Asperger syndrome during less-busy days and times, and avoid surprises during medical examinations or procedures, as the unexpected often triggers an extreme reaction. Examinations and procedures should be conducted in a deliberate and slow manner, as rushing through the examination raises the risk of complicating the outcome. Care should also be taken to simplify communications to accommodate the language constraints of the patient.

ONGOING TREATMENT: THE PROMISE OF TECHNOLOGY

Access to support services is critical—especially as people with Asperger syndrome move into adulthood—while the apparent rise in the prevalence of Asperger syndrome and other forms of autism spectrum disorder call for an expansion of current service models. Typically eager to address areas of social deficit, people with Asperger syndrome could benefit from ongoing social-skills support.

Mobile devices such as tablets and smart phones are a transformative technology that shows great promise in supporting treatment innovation. I believe they will have the greatest impact on quality of life for patients with Asperger syndrome by enhancing the potential to live completely independently or semi-independently. These devices can function as personal assistants for those who experience difficulty with time management, human connectivity, way-finding, and other tasks. We have observed, for example, that visual connectivity with caregivers (and others) through a cell phone, messaging, or video chatting, or the provision of electronic reminders for medications or appointments, can reduce the anxiety of a child with Asperger syndrome living outside the parental home. It can also help the physician better ensure that treatment regimens are being followed. Finally, an endless supply of entertainment “apps” along with robust search engines to suit every interest is afforded by feature-rich mobile devices.

Armed with these gadgets, therapists now tailor support to meet the patient’s individual needs, which can range from basic social-skills development and social-cue reminders to higher-level conversational and organizational supports. New tools and techniques, along with better understanding of the condition, portend far more innovative and improved treatments for the future.

In this issue of the Cleveland Clinic Journal of Medicine, Prayson and Franco paint a comprehensive picture of the key medical and therapeutic issues faced by patients with Asperger syndrome.¹ They offer a refreshing optimism about contemporary treatments aimed at enhancing independence and quality of life, while being realistic about the challenges for these patients, such as making the transition from pediatric care to adult care. Importantly, their overview offers practical suggestions for improving medical care through a greater understanding of the syndrome, along with strategies for how to relate to patients who have a difficult interpersonal style.

See related article

In this editorial, I focus on lessons learned in our practice that help identify the problems that people with Asperger syndrome have, and I build on the advice of Prayson and Franco on how to improve patient experiences in the adult medical setting, particularly by diminishing confusion and uncertainty in doctor-patient interactions and by supporting ongoing functioning.

PEOPLE WITH ASPERGER SYNDROME HAVE ALWAYS LIVED AMONG US

Asperger syndrome is being diagnosed more frequently, using criteria recognized by a greater number of professionals. This diagnostic distinction offers a clearer understanding of a group of people who have always lived among us—often standing out because of their appearance, behavior, and communication style, even before a common label existed for their condition.

In less-informed communities, they might be described by neighbors or peers as eccentric or odd, even when they present no obvious dysmorphic or other distinguishing physical features. In fact, some may stand out more because of their accomplishments. The behaviors reported for some innovative scientists (Einstein), inventors (Ford, Edison), musicians (Beethoven), and others might lead to a diagnosis of Asperger syndrome today, while an obsessive nature also characteristic of Asperger syndrome might well have enabled them to think and create in astonishing ways.

As we have come to understand this syndrome better, we have recognized that it is a spectrum. Some patients are highly functioning, for example, and different patients have different needs.

Steve Silberman,² writing for Wired magazine, coined the term “geek syndrome” and suggested that geeks marrying geeks may help account for the comparatively high prevalence of autism and Asperger syndrome in “techheavy” communities such as Silicon Valley in California and Route 128 in Massachusetts. “At clinics and schools in the Valley, the observation that most parents of autistic kids are engineers and programmers who themselves display autistic behavior is not news.”² Temple Grandin, arguably the best-known person with an autism spectrum condition, has characterized the NASA Space Center in Houston, TX, as a similar community.

Given this correlation, it follows that colleges and universities offering engineering, computer science, and other technical programs or degrees should have a relatively high prevalence of students with Asperger syndrome. The Massachusetts Institute of Technology, where such a pattern is often observed, offers a course entitled “Charm School,” and its online course description is suggestive of the unique needs of this population³:

“How do I ask for a date? Which bread plate is mine? At what point in a job interview can I ask about salary? Should I use a cell phone while on the T or the elevator? How can a student network to find the perfect position? Join us for MIT's 19th Annual Charm School to find out these answers and more.”

COMMUNICATION DISTURBANCES

The challenges a person with Asperger syndrome may be experiencing are often very difficult to understand. While these people may look normal and demonstrate average to above-average intellectual functioning, their sometimes-peculiar behaviors and deficits in social skills are often difficult for peers to interpret— and to forgive. People with Asperger syndrome want to get along with peers, develop relationships, and succeed in the workplace, and they feel perplexed that others sometimes seem put off by their behavior.

At the core of this discomfort are a range of communication disorders that negatively affect interactions with others. One practical indication of a communication disorder is whether more attention is paid to how something is said than what is being said. This may present to the physician in different ways.

Language

Difficulty with introspection and description may render a patient incapable of describing symptoms and related historical information. In addition, the idiomatic and figurative nature of English may lead Asperger syndrome patients to misunderstand what the physician is saying—even common nonliteral expressions such as “Hop up on the table,” “You’re as fit as a fiddle,” “Are you feeling under the weather?” and “I’m all ears.”

Speech and voice

For the person with Asperger syndrome, speech is often marked by prosodic disturbances, including problems with varying and atypical intonation and stress and, less commonly, unusual fluency patterns and residual articulation issues (l, r, and s sounds). These characteristics can be addressed in therapy.

Conversational style

When people with Asperger syndrome engage in conversation, it is usually brief, or they tend to monopolize it with topics of high interest to themselves or topics of a perseverative or obsessive nature. The patient also tends to have limited perspective and experiences difficulty with higher-order language (including inference and reasoning).

Nonverbal language

A host of nonverbal communication problems include the use of unacceptable social distance and the unintentional messages conveyed nonverbally by unusual clothing choices and poor grooming and hygiene.

WHAT CAN BE DONE IN THE OFFICE VISIT

The key to a successful visit with such patients is to help them anticipate and make sense of their experience. In the visit, predictability should be emphasized and “chaos” avoided. Try to schedule the patient with Asperger syndrome during less-busy days and times, and avoid surprises during medical examinations or procedures, as the unexpected often triggers an extreme reaction. Examinations and procedures should be conducted in a deliberate and slow manner, as rushing through the examination raises the risk of complicating the outcome. Care should also be taken to simplify communications to accommodate the language constraints of the patient.

ONGOING TREATMENT: THE PROMISE OF TECHNOLOGY

Access to support services is critical—especially as people with Asperger syndrome move into adulthood—while the apparent rise in the prevalence of Asperger syndrome and other forms of autism spectrum disorder call for an expansion of current service models. Typically eager to address areas of social deficit, people with Asperger syndrome could benefit from ongoing social-skills support.

Mobile devices such as tablets and smart phones are a transformative technology that shows great promise in supporting treatment innovation. I believe they will have the greatest impact on quality of life for patients with Asperger syndrome by enhancing the potential to live completely independently or semi-independently. These devices can function as personal assistants for those who experience difficulty with time management, human connectivity, way-finding, and other tasks. We have observed, for example, that visual connectivity with caregivers (and others) through a cell phone, messaging, or video chatting, or the provision of electronic reminders for medications or appointments, can reduce the anxiety of a child with Asperger syndrome living outside the parental home. It can also help the physician better ensure that treatment regimens are being followed. Finally, an endless supply of entertainment “apps” along with robust search engines to suit every interest is afforded by feature-rich mobile devices.

Armed with these gadgets, therapists now tailor support to meet the patient’s individual needs, which can range from basic social-skills development and social-cue reminders to higher-level conversational and organizational supports. New tools and techniques, along with better understanding of the condition, portend far more innovative and improved treatments for the future.

In this issue of the Cleveland Clinic Journal of Medicine, Prayson and Franco paint a comprehensive picture of the key medical and therapeutic issues faced by patients with Asperger syndrome.¹ They offer a refreshing optimism about contemporary treatments aimed at enhancing independence and quality of life, while being realistic about the challenges for these patients, such as making the transition from pediatric care to adult care. Importantly, their overview offers practical suggestions for improving medical care through a greater understanding of the syndrome, along with strategies for how to relate to patients who have a difficult interpersonal style.

See related article

In this editorial, I focus on lessons learned in our practice that help identify the problems that people with Asperger syndrome have, and I build on the advice of Prayson and Franco on how to improve patient experiences in the adult medical setting, particularly by diminishing confusion and uncertainty in doctor-patient interactions and by supporting ongoing functioning.

PEOPLE WITH ASPERGER SYNDROME HAVE ALWAYS LIVED AMONG US

Asperger syndrome is being diagnosed more frequently, using criteria recognized by a greater number of professionals. This diagnostic distinction offers a clearer understanding of a group of people who have always lived among us—often standing out because of their appearance, behavior, and communication style, even before a common label existed for their condition.

In less-informed communities, they might be described by neighbors or peers as eccentric or odd, even when they present no obvious dysmorphic or other distinguishing physical features. In fact, some may stand out more because of their accomplishments. The behaviors reported for some innovative scientists (Einstein), inventors (Ford, Edison), musicians (Beethoven), and others might lead to a diagnosis of Asperger syndrome today, while an obsessive nature also characteristic of Asperger syndrome might well have enabled them to think and create in astonishing ways.

As we have come to understand this syndrome better, we have recognized that it is a spectrum. Some patients are highly functioning, for example, and different patients have different needs.

Steve Silberman,² writing for Wired magazine, coined the term “geek syndrome” and suggested that geeks marrying geeks may help account for the comparatively high prevalence of autism and Asperger syndrome in “techheavy” communities such as Silicon Valley in California and Route 128 in Massachusetts. “At clinics and schools in the Valley, the observation that most parents of autistic kids are engineers and programmers who themselves display autistic behavior is not news.”² Temple Grandin, arguably the best-known person with an autism spectrum condition, has characterized the NASA Space Center in Houston, TX, as a similar community.

Given this correlation, it follows that colleges and universities offering engineering, computer science, and other technical programs or degrees should have a relatively high prevalence of students with Asperger syndrome. The Massachusetts Institute of Technology, where such a pattern is often observed, offers a course entitled “Charm School,” and its online course description is suggestive of the unique needs of this population³:

“How do I ask for a date? Which bread plate is mine? At what point in a job interview can I ask about salary? Should I use a cell phone while on the T or the elevator? How can a student network to find the perfect position? Join us for MIT's 19th Annual Charm School to find out these answers and more.”

COMMUNICATION DISTURBANCES

The challenges a person with Asperger syndrome may be experiencing are often very difficult to understand. While these people may look normal and demonstrate average to above-average intellectual functioning, their sometimes-peculiar behaviors and deficits in social skills are often difficult for peers to interpret— and to forgive. People with Asperger syndrome want to get along with peers, develop relationships, and succeed in the workplace, and they feel perplexed that others sometimes seem put off by their behavior.

At the core of this discomfort are a range of communication disorders that negatively affect interactions with others. One practical indication of a communication disorder is whether more attention is paid to how something is said than what is being said. This may present to the physician in different ways.

Language

Difficulty with introspection and description may render a patient incapable of describing symptoms and related historical information. In addition, the idiomatic and figurative nature of English may lead Asperger syndrome patients to misunderstand what the physician is saying—even common nonliteral expressions such as “Hop up on the table,” “You’re as fit as a fiddle,” “Are you feeling under the weather?” and “I’m all ears.”

Speech and voice

For the person with Asperger syndrome, speech is often marked by prosodic disturbances, including problems with varying and atypical intonation and stress and, less commonly, unusual fluency patterns and residual articulation issues (l, r, and s sounds). These characteristics can be addressed in therapy.

Conversational style

When people with Asperger syndrome engage in conversation, it is usually brief, or they tend to monopolize it with topics of high interest to themselves or topics of a perseverative or obsessive nature. The patient also tends to have limited perspective and experiences difficulty with higher-order language (including inference and reasoning).

Nonverbal language

A host of nonverbal communication problems include the use of unacceptable social distance and the unintentional messages conveyed nonverbally by unusual clothing choices and poor grooming and hygiene.

WHAT CAN BE DONE IN THE OFFICE VISIT

The key to a successful visit with such patients is to help them anticipate and make sense of their experience. In the visit, predictability should be emphasized and “chaos” avoided. Try to schedule the patient with Asperger syndrome during less-busy days and times, and avoid surprises during medical examinations or procedures, as the unexpected often triggers an extreme reaction. Examinations and procedures should be conducted in a deliberate and slow manner, as rushing through the examination raises the risk of complicating the outcome. Care should also be taken to simplify communications to accommodate the language constraints of the patient.

ONGOING TREATMENT: THE PROMISE OF TECHNOLOGY

Access to support services is critical—especially as people with Asperger syndrome move into adulthood—while the apparent rise in the prevalence of Asperger syndrome and other forms of autism spectrum disorder call for an expansion of current service models. Typically eager to address areas of social deficit, people with Asperger syndrome could benefit from ongoing social-skills support.

Mobile devices such as tablets and smart phones are a transformative technology that shows great promise in supporting treatment innovation. I believe they will have the greatest impact on quality of life for patients with Asperger syndrome by enhancing the potential to live completely independently or semi-independently. These devices can function as personal assistants for those who experience difficulty with time management, human connectivity, way-finding, and other tasks. We have observed, for example, that visual connectivity with caregivers (and others) through a cell phone, messaging, or video chatting, or the provision of electronic reminders for medications or appointments, can reduce the anxiety of a child with Asperger syndrome living outside the parental home. It can also help the physician better ensure that treatment regimens are being followed. Finally, an endless supply of entertainment “apps” along with robust search engines to suit every interest is afforded by feature-rich mobile devices.

Armed with these gadgets, therapists now tailor support to meet the patient’s individual needs, which can range from basic social-skills development and social-cue reminders to higher-level conversational and organizational supports. New tools and techniques, along with better understanding of the condition, portend far more innovative and improved treatments for the future.

In 1944, Hans Asperger described a subset of children who exhibited “a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest, and clumsy movements.”¹

In recent years, Asperger syndrome has become increasingly recognized in the medical community and by the general public. It has been popularized in the media in John Elder Robison’s bestselling book, Look Me in the Eye; with the television character Sheldon Cooper in The Big Bang Theory; and in the 2009 film, Adam, a romantic comedy with the title character accurately portraying a young man with Asperger syndrome.

See related editorial

In this article, we discuss the causes and characteristics of Asperger syndrome, with special focus on adults: how it presents, how to treat it, and how to enhance the delivery of care.

PREVALENCE SEEMS TO BE INCREASING

One in 88 children is diagnosed with an autism spectrum disorder, and the rates of Asperger syndrome and other autism spectrum disorders appear to be increasing.² Whether this increase is the result of more thorough assessment and identification or of environmental changes is hotly debated.³ The rise began before the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified to simplify diagnosis.⁴ Asperger syndrome affects males three to four times more often than females.⁵ For most patients, the effects persist throughout life.

BEHAVIORAL IMPAIRMENTS CHARACTERIZE THE SYNDROME

Poor social skills are a hallmark

People with Asperger syndrome struggle with social interaction and face challenges in forming and maintaining relationships. They tend to have less eye contact (often the first indicator), smiling, animated speech, and physical communication such as hand gestures. They tend not to solicit another’s attention to something they themselves find interesting. They often lack social and emotional reciprocity and have difficulty understanding another person’s thoughts or feelings,⁶ and they have marked difficulty reading social cues. Some adults may appear rigid, selfish, or narrow-minded.

Sometimes behavior is in the normal range but is out of context for a particular situation.⁷ For example, a preprofessional student with Asperger syndrome might walk into a psychiatric evaluation to assess fitness for duty and take a seat cross-legged on the floor and have a snack. Poor grooming inappropriate for the occasion may also be observed, such as showing up for a formal photo with unkempt hair and in a stained shirt that is half tucked in.

Many adults with autism spectrum disorders are oblivious to their social reputation.⁸ They are often unaware that their behavior is out of place and only learn that it is not normal when they are told. Others recognize that they have trouble empathizing with or understanding the perspectives of others, but they are at a loss as to how to improve. The syndrome has a tremendous impact on broader aspects of life, such as employment, functional independence, relationships, and social networks.

Other odd behaviors are common

Repetitive behaviors. Many patients with Asperger syndrome have repetitive behaviors, which can manifest as repeating phrases or expressions, attempting to imitate others, and rocking. They tend to follow routines, do not enjoy spontaneity, and are more inflexible and uncomfortable when their planned regimen is altered.

Gait or balance issues may be observed on physical examination.⁹ Uncoordinated motion and clumsiness are common,¹⁰ and some patients may have a bouncy, stilted gait or may walk on their toes, although the latter is more common in children than adults. Many patients have illegible handwriting.¹¹

Fixations. Many Asperger patients have unusual and intense obsessions with subjects like numbers, dates, or aerodynamics of planes. Children with such fascinations are described as “little professors” or as having “geek syndrome.”¹² Certain obsessions often continue into adulthood, although one area of interest may fade and another may take over. Such “expertise” in adults may gain them respect, even though they may seem very odd in other ways.

Lack of boundaries. Patients with Asperger syndrome tend to have poor spatial awareness and to be unaware of physical boundaries, standing too close for others’ comfort or unusually far away. Lack of boundaries may extend beyond the physical, as patients may inappropriately help themselves to food or use an item belonging to another without invitation, being unaware that the behavior may be intrusive or inappropriate.

BEHAVIORAL ASSESSMENTS HELP MAKE DIAGNOSIS

Asperger syndrome is most often diagnosed in early childhood, although it may remain undiagnosed into adulthood. Coexisting depression, attention deficit hyperactivity disorder, or anxiety disorders are also often present.

Establishing the diagnosis is aided by information from family members and others who interact with the patient, from the observations of trained professionals, and from self-reported data. However, self-reported assessments are not always reliable, because the syndrome can affect insight.

The most common assessment tool for autism spectrum disorders is the Autism Diagnostic Interview-Revised (ADI-R),¹³ a battery of tests given in a structured interview to identify and quantify symptoms, determine where a patient falls on the autism spectrum,¹⁴ and point toward interventions. The ADI-R also organizes critical developmental history to evaluate if something else is present, such as prodromal schizophrenia. Although the ADI-R can be very useful in the diagnostic process, it is based on parental reporting, which is neither always available nor fully reliable.

A specific diagnostic tool for adults is the Adult Asperger Assessment.¹⁵ Patients are asked to complete two screening questionnaires that gauge cognitive function and gather information about thinking, processing, and behavior.

Table 1 lists the criteria for Asperger syndrome from the DSM Fourth Edition, Text Revision (DSM-IV-TR).¹⁶ Asperger syndrome differs from general autism in that it is not associated with language delay. In addition, patients with Asperger syndrome usually have average or above-average IQ scores.¹⁷ Still, determining whether a patient has Asperger syndrome or high-functioning autism is sometimes challenging.⁶

In DSM-V, Asperger syndrome will be subsumed under autism spectrum disorder

In 2013, the DSM-V will replace the DSMIV-TR and will combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise classified into a single diagnosis: autism spectrum disorder. The new system uses two instead of the previous three clusters of core symptoms, centered on “social reciprocity and communication” in one arm and “restricted interests and repetitive behavior” in the other.¹⁸ There will be less emphasis on play and imagination than in the past. Some authors suggest adding sensory criteria, particularly reduced pain and increased hearing sensitivity.¹⁹

The proposed system is sensitive and specific for autism spectrum disorders, allows early diagnosis, and indicates degree of severity.²⁰ It is hoped that the new system, which accounts for the range and severity of symptoms, should help physicians refer patients to the correct level of treatment.

On the other hand, it may be difficult to think of the three disorders as a single diagnosis. Asperger syndrome manifests in distinct ways, and clear behavioral criteria for diagnosis can be invaluable in helping people with the syndrome. Also, the public may continue to refer to it as Asperger syndrome, and parents and patients may feel uncomfortable having it considered to be the same diagnosis as autism.

BEHAVIORAL THERAPY CAN HELP ACHIEVE INDEPENDENCE

Although there is no cure for Asperger syndrome, various interventions can dramatically improve quality of life and independence. The health care team may include a primary care physician, psychologist, psychiatrist, neurologist, and speech therapist.

Behavioral therapies can help patients with Asperger syndrome learn skills to reduce their symptoms. Occupational and physical therapy can improve dexterity, fluidity, and coordination. Desensitization training may help patients adapt to uncomfortable sights, sounds, or smells that may arise. This can be critical in a job situation. For example, while an average person exposed to a foul odor in public is likely to react tactfully, a person with Asperger syndrome may scream loudly, make inappropriate comments, or run from the room. Social training, especially targeted to the workplace, can provide strategies for promoting typical behaviors and be key to maximizing functional independence.

Speech therapists can teach patients how to sound more relaxed and help them master the natural give-and-take of conversational exchange. Psychotherapy can provide a safe place to work on anxiety, express emotions, and manage restricted interests or repeated behaviors. Group therapy or social training can be a venue for learning improved interactions.

Living independently can be very challenging, and patients with Asperger syndrome may need functional independence training to help with a variety of skills, from handling finances to organizing the home.

Improving quality of life includes determining the best learning environments from childhood into college years and beyond.^21–23 Socialization can be enhanced with additional social support at home or on campus, through family interactions and collaborative learning, and by teaching empathy.²⁴ Vocational training can be extremely useful.

DRUG THERAPY MAY HAVE A ROLE

Medications are not usually prescribed unless depression or anxiety is also present, but they may also help manage irritability, anger, stereotypical mannerisms, and disturbing movements. Fluoxetine (Prozac) helps reduce repetitive behaviors in adults with Asperger syndrome. Propranolol (Inderal), a well-known antihypertensive, is also used for performance anxiety and improves word fluency, understanding of verbal communication, and verbal problem-solving in patients with an autism spectrum disorder.²⁵

Giving oxytocin (Pitocin) intranasally in a spray formulation is currently being tested to enhance social skills. Patients with an autism spectrum disorder were more able to perceive emotions of others and to respond more appropriately.²⁶ Oxytocin has long been associated with bonding and is believed to enhance mothering skills. It is naturally present in both sexes, but levels are higher in women, which may in part explain the lower rate of autism spectrum disorders in females.²⁷

HEALTH CARE REQUIRES SPECIAL CONSIDERATIONS

Medical care for patients with Asperger syndrome is enhanced by understanding the patient’s experience. Adults, in particular, may have learned to suppress symptoms of Asperger syndrome to better function in society but still experience stress in situations in which others would not. Patients with Asperger syndrome may struggle with social interactions during medical examinations or procedures, and clinicians may find interaction with the patient challenging.

It is important for health care providers to be calm and patient and to understand that anxiety may prevent people with Asperger syndrome from making eye contact. The clinician should confirm that a patient is engaged but should avoid seeming pushy or invasive.

When anxious, patients may employ strange gestures that they find soothing, such as flapping the hands, rocking, or cracking the knuckles. It is usually easier to allow them to continue unless the activity hinders the examination or treatment.

Patients are likely to respond better to direct requests than to subtle questions: eg, “Open your mouth, please” instead of “Could you open your mouth?” Using clear, specific language and avoiding metaphors, irony, and nonverbal communication are best. It is important to explicitly ask for everything needed, as patients may not volunteer information and may have trouble articulating what they are thinking or feeling. While educating patients about their health needs, physicians may need to reiterate guidance several times or approach the same topic from different angles in order for the patient to accept a concern.

All actions, especially touching the patient, should be explained clearly beforehand. If possible, the doctor should demonstrate using visuals or on his or her own body if appropriate. For invasive procedures, anesthetizing the local area is recommended.

People with Asperger syndrome often rely heavily on a regular routine to maintain a sense of organization. By interrupting this routine, a doctor’s visit can induce anxiety. Waiting also increases anxiety, so scheduling patients with Asperger syndrome either first or last in the day may help.

Hypersensitivity poses challenges

Many people with Asperger syndrome have abnormal sensitivity to stimuli, with differences in pain sensation and hearing perhaps most prominent. Loud noises, such as beeping equipment, whirring fans, or buzzing lights may be distressful and should be reduced if possible. Patients may also be strongly affected by bright lights or scents such as perfumes.

Patients may also have an altered sense of taste, with consequences that go beyond simple “picky eating.” Patients should be asked about unusual eating patterns, diets, or food aversions. People with autism spectrum disorders often do not consume adequate vitamin C because of an aversion to fruits and vegetables. Vitamin deficiency may have originated in infancy but may not be identified or treated until adulthood.²⁸

The sense of touch may be intensified, causing patients to be extremely ticklish; they may actually prefer to be touched more firmly. When it is necessary to make physical contact with patients, it will make the process easier if the physician determines their comfort level and finds ways to help them endure the experience with the least amount of discomfort.

Some patients with impaired sensory expression may have a high tolerance for extreme temperatures and pain, leading to delay in seeking aid.²⁹ Patients may downgrade pain levels, masking the severity of an illness or injury.

Transition from pediatric to adult care

Pediatrics is often a warm environment in which children develop a trusting relationship with their care providers. The transition to adult care can be daunting for patients with Asperger syndrome and their families, and many postpone the change for as long as possible.

Although time-consuming, a collaborative effort between the pediatric and adult care teams can dramatically smooth the transition. It can help to have a familiar person from the pediatric team, such as a nurse, be present at the initial interaction with the new adult care team. Both teams should be familiar with the other’s clinical practices and be aware of the patient’s stressors and ways to ameliorate them.³⁰

THE SEARCH FOR A CAUSE CONTINUES

Numerous studies are attempting to understand the anatomic and physiologic causes of autism spectrum disorders, and to find effective treatments and improve the quality of life.

Prenatal factors implicated

Several recent studies have focused on environmental factors during pregnancy as risk factors for autism spectrum disorder. Selective serotonin reuptake inhibitors were found to increase the risk,³¹ but the severity of the mother’s depressive illness must be considered before counseling against using these drugs. Older maternal or paternal age was also found to increase the risk of an autism spectrum disorder.³² Recent research indicates that older fathers are in particular more likely to have children with disorders such as autism because of an increase in random mutations associated with advanced age.³³

Maternal illness during pregnancy is also associated. Preliminary studies found an increased risk of autism if the mother had had a prenatal viral infection.³⁴ A more recent study found that untreated fever during pregnancy rather than a specific viral infection is more strongly linked.³⁵

Maternal antibodies have been implicated as well. One review found that psoriasis is the only maternal autoimmune condition significantly associated with the development of an autism spectrum disorder.³⁶ Elevated levels of antibodies against the fetal brain have been found in mothers with autistic children.³⁷ One study found that autistic children and their siblings have elevated antibrain antibodies in distinct brain regions, including the caudate nucleus, putamen, prefrontal cortex, cerebellum, and cingulate gyrus (why the siblings are spared from having the disorder is unclear).³⁸ Some have questioned whether a child’s own immune system might even be involved.³⁹

Functional magnetic resonance imaging (fMRI) has been used to investigate impaired social interaction, specific deficits of facial perception and recognition, sensory processing, working memory, and “theory of mind.” Hypoactivation, hyperactivation, and decreased functional connectivity have been observed depending on the mental processes evaluated.⁴⁰

When undergoing facial perception tasks, subjects with autism spectrum disorders exhibit hypoactivation in the lateral aspect of the middle region of the fusiform gyrus, responsible for face identification. But they have significant activation of the limbic system, specifically the amygdala, during facial recognition. Hypoactivity in the fusiform gyrus is observed when trying to identify faces or read facial expressions.^41,42 This cluster of findings helps explain misinterpretations, misidentification, and heightened affect.

A hallmark characteristic of autism is the difficulty patients have in determining intentions and interpreting others’ behavior, thoughts, or emotions. Studies of people with autism spectrum disorders show that areas often responsible for “sensitivity to others” are hypoactive.⁴³ There is also diminished activation in the medial cingulate cortex, normally activated when these people are asked to think about themselves and who they are.⁴⁴

The resting state in the brains of people with autism spectrum disorders is abnormally activated.⁴⁵ They are often particularly good at attention to detail but challenged in integrating information needed for general executive functioning. Impaired sensory processing makes it difficult for them to simultaneously interpret multiple sources of sensory input.⁴⁶

Perhaps some of the most exciting fMRI news comes from infant studies. Radical and axial diffusivity and fractional anisotropy techniques demonstrate differences in the brains of infants 6 to 24 months old, before symptoms of autism spectrum disorders are observed. It is hoped that early intervention could come into play before the syndrome develops fully.⁴⁷

The synthesis of input of social and emotional cues is sometimes referred to in the literature as “theory of mind.” It is impaired in Asperger syndrome,⁴⁸ as manifested by a lack of empathy and by challenges in perceiving others’ thoughts and feelings. The basis of impairment may be related to abnormalities in the amygdala.⁴⁹ Normal awareness involves the integration of multiple neural networks in the anterior paracingulate cortex, the superior temporal sulci, and the temporal poles bilaterally, but different regions appear to be used in patients with Asperger syndrome.⁵⁰ A small series of five case studies using positron emission tomography indicated that the left prefrontal cortex was the primary location for theory of mind in Asperger syndrome.⁵¹

Epilepsy, gastrointestinal problems, and sleep disturbances are associated

About 25% of people with autism spectrum disorders have epilepsy vs 2% to 3% in the general population. Asperger syndrome is associated with a much lower but still elevated risk of 4% to 6%.^47,52

Gastrointestinal complaints, most often constipation or chronic diarrhea, are much more common in children with autism spectrum disorders than in the general population. Preliminary data showed that children with an autism spectrum disorder have a 42% rate of gastrointestinal problems vs 12% in unaffected siblings. There is also a correlation between the severity of gastrointestinal problems and severity of autistic symptoms.⁵³

Research is ongoing to determine the prevalence of insomnia or interrupted sleep in those with autism spectrum disorders.^54–56 Changes in sleep architecture can explain nighttime activity.

NONTRADITIONAL CONSIDERATIONS

Dietary treatment: Mixed findings

A popular hypothesis is that adherence to a gluten-free or casein-free diet can reduce symptoms of autism spectrum disorders. Preliminary reports identified several cases of children showing improvement.⁵⁷ However, this has not been replicated, and more studies refute benefits of these diets.⁵⁸

Essential nutritional needs should be met with any diet, whether it is designed to reduce symptoms or not. Patients with autism spectrum disorders may have strong food aversions, and dietary supplements of vitamins and minerals may be required.

Vaccines do not cause autism

Despite popular concern, recent research indicates that vaccines do not cause autism. Thimerosal, a mercury-based preservative used in childhood vaccines, was at one time implicated as a risk factor for autism spectrum disorders. The US Centers for Disease Control and Prevention (CDC) issued a precaution against using thimerosal-containing vaccines while testing was done to determine the effects on neuropsychological development.⁵⁹ The CDC study as well as newer studies did not demonstrate that exposure to mercury causes these neuropsychological concerns, but researchers have continued to study the subject.^60–62 The original study implicating thimerosal was disproven as scientifically unsound and fraught with conflict of interest and legal concerns. It has since been retracted, and its findings have been completely discredited.⁶³

Other areas of research

Current research is exploring the higher prevalence of autism spectrum disorders in particular families.^64–66 Autism and autism spectrum disorders may be caused by hundreds of simultaneous gene alterations or may develop as a result of reduced gene expression in two areas of the cerebral cortex where higher-order processing occurs, in the frontal and temporal lobes.⁶⁷

Although genetic theories of autism predominate, a 2011 project suggests that environment is also important. A study of twins found that genetics accounted for 40% or less of cases of autism spectrum disorder, with at least 55% of cases being attributable to environmental factors.⁶⁸

In 1944, Hans Asperger described a subset of children who exhibited “a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest, and clumsy movements.”¹

In recent years, Asperger syndrome has become increasingly recognized in the medical community and by the general public. It has been popularized in the media in John Elder Robison’s bestselling book, Look Me in the Eye; with the television character Sheldon Cooper in The Big Bang Theory; and in the 2009 film, Adam, a romantic comedy with the title character accurately portraying a young man with Asperger syndrome.

See related editorial

In this article, we discuss the causes and characteristics of Asperger syndrome, with special focus on adults: how it presents, how to treat it, and how to enhance the delivery of care.

PREVALENCE SEEMS TO BE INCREASING

One in 88 children is diagnosed with an autism spectrum disorder, and the rates of Asperger syndrome and other autism spectrum disorders appear to be increasing.² Whether this increase is the result of more thorough assessment and identification or of environmental changes is hotly debated.³ The rise began before the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified to simplify diagnosis.⁴ Asperger syndrome affects males three to four times more often than females.⁵ For most patients, the effects persist throughout life.

BEHAVIORAL IMPAIRMENTS CHARACTERIZE THE SYNDROME

Poor social skills are a hallmark

People with Asperger syndrome struggle with social interaction and face challenges in forming and maintaining relationships. They tend to have less eye contact (often the first indicator), smiling, animated speech, and physical communication such as hand gestures. They tend not to solicit another’s attention to something they themselves find interesting. They often lack social and emotional reciprocity and have difficulty understanding another person’s thoughts or feelings,⁶ and they have marked difficulty reading social cues. Some adults may appear rigid, selfish, or narrow-minded.

Sometimes behavior is in the normal range but is out of context for a particular situation.⁷ For example, a preprofessional student with Asperger syndrome might walk into a psychiatric evaluation to assess fitness for duty and take a seat cross-legged on the floor and have a snack. Poor grooming inappropriate for the occasion may also be observed, such as showing up for a formal photo with unkempt hair and in a stained shirt that is half tucked in.

Many adults with autism spectrum disorders are oblivious to their social reputation.⁸ They are often unaware that their behavior is out of place and only learn that it is not normal when they are told. Others recognize that they have trouble empathizing with or understanding the perspectives of others, but they are at a loss as to how to improve. The syndrome has a tremendous impact on broader aspects of life, such as employment, functional independence, relationships, and social networks.

Other odd behaviors are common

Repetitive behaviors. Many patients with Asperger syndrome have repetitive behaviors, which can manifest as repeating phrases or expressions, attempting to imitate others, and rocking. They tend to follow routines, do not enjoy spontaneity, and are more inflexible and uncomfortable when their planned regimen is altered.

Gait or balance issues may be observed on physical examination.⁹ Uncoordinated motion and clumsiness are common,¹⁰ and some patients may have a bouncy, stilted gait or may walk on their toes, although the latter is more common in children than adults. Many patients have illegible handwriting.¹¹

Fixations. Many Asperger patients have unusual and intense obsessions with subjects like numbers, dates, or aerodynamics of planes. Children with such fascinations are described as “little professors” or as having “geek syndrome.”¹² Certain obsessions often continue into adulthood, although one area of interest may fade and another may take over. Such “expertise” in adults may gain them respect, even though they may seem very odd in other ways.

Lack of boundaries. Patients with Asperger syndrome tend to have poor spatial awareness and to be unaware of physical boundaries, standing too close for others’ comfort or unusually far away. Lack of boundaries may extend beyond the physical, as patients may inappropriately help themselves to food or use an item belonging to another without invitation, being unaware that the behavior may be intrusive or inappropriate.

BEHAVIORAL ASSESSMENTS HELP MAKE DIAGNOSIS

Asperger syndrome is most often diagnosed in early childhood, although it may remain undiagnosed into adulthood. Coexisting depression, attention deficit hyperactivity disorder, or anxiety disorders are also often present.

Establishing the diagnosis is aided by information from family members and others who interact with the patient, from the observations of trained professionals, and from self-reported data. However, self-reported assessments are not always reliable, because the syndrome can affect insight.

The most common assessment tool for autism spectrum disorders is the Autism Diagnostic Interview-Revised (ADI-R),¹³ a battery of tests given in a structured interview to identify and quantify symptoms, determine where a patient falls on the autism spectrum,¹⁴ and point toward interventions. The ADI-R also organizes critical developmental history to evaluate if something else is present, such as prodromal schizophrenia. Although the ADI-R can be very useful in the diagnostic process, it is based on parental reporting, which is neither always available nor fully reliable.

A specific diagnostic tool for adults is the Adult Asperger Assessment.¹⁵ Patients are asked to complete two screening questionnaires that gauge cognitive function and gather information about thinking, processing, and behavior.

Table 1 lists the criteria for Asperger syndrome from the DSM Fourth Edition, Text Revision (DSM-IV-TR).¹⁶ Asperger syndrome differs from general autism in that it is not associated with language delay. In addition, patients with Asperger syndrome usually have average or above-average IQ scores.¹⁷ Still, determining whether a patient has Asperger syndrome or high-functioning autism is sometimes challenging.⁶

In DSM-V, Asperger syndrome will be subsumed under autism spectrum disorder

In 2013, the DSM-V will replace the DSMIV-TR and will combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise classified into a single diagnosis: autism spectrum disorder. The new system uses two instead of the previous three clusters of core symptoms, centered on “social reciprocity and communication” in one arm and “restricted interests and repetitive behavior” in the other.¹⁸ There will be less emphasis on play and imagination than in the past. Some authors suggest adding sensory criteria, particularly reduced pain and increased hearing sensitivity.¹⁹

The proposed system is sensitive and specific for autism spectrum disorders, allows early diagnosis, and indicates degree of severity.²⁰ It is hoped that the new system, which accounts for the range and severity of symptoms, should help physicians refer patients to the correct level of treatment.

On the other hand, it may be difficult to think of the three disorders as a single diagnosis. Asperger syndrome manifests in distinct ways, and clear behavioral criteria for diagnosis can be invaluable in helping people with the syndrome. Also, the public may continue to refer to it as Asperger syndrome, and parents and patients may feel uncomfortable having it considered to be the same diagnosis as autism.

BEHAVIORAL THERAPY CAN HELP ACHIEVE INDEPENDENCE

Although there is no cure for Asperger syndrome, various interventions can dramatically improve quality of life and independence. The health care team may include a primary care physician, psychologist, psychiatrist, neurologist, and speech therapist.

Behavioral therapies can help patients with Asperger syndrome learn skills to reduce their symptoms. Occupational and physical therapy can improve dexterity, fluidity, and coordination. Desensitization training may help patients adapt to uncomfortable sights, sounds, or smells that may arise. This can be critical in a job situation. For example, while an average person exposed to a foul odor in public is likely to react tactfully, a person with Asperger syndrome may scream loudly, make inappropriate comments, or run from the room. Social training, especially targeted to the workplace, can provide strategies for promoting typical behaviors and be key to maximizing functional independence.

Speech therapists can teach patients how to sound more relaxed and help them master the natural give-and-take of conversational exchange. Psychotherapy can provide a safe place to work on anxiety, express emotions, and manage restricted interests or repeated behaviors. Group therapy or social training can be a venue for learning improved interactions.

Living independently can be very challenging, and patients with Asperger syndrome may need functional independence training to help with a variety of skills, from handling finances to organizing the home.

Improving quality of life includes determining the best learning environments from childhood into college years and beyond.^21–23 Socialization can be enhanced with additional social support at home or on campus, through family interactions and collaborative learning, and by teaching empathy.²⁴ Vocational training can be extremely useful.

DRUG THERAPY MAY HAVE A ROLE

Medications are not usually prescribed unless depression or anxiety is also present, but they may also help manage irritability, anger, stereotypical mannerisms, and disturbing movements. Fluoxetine (Prozac) helps reduce repetitive behaviors in adults with Asperger syndrome. Propranolol (Inderal), a well-known antihypertensive, is also used for performance anxiety and improves word fluency, understanding of verbal communication, and verbal problem-solving in patients with an autism spectrum disorder.²⁵

Giving oxytocin (Pitocin) intranasally in a spray formulation is currently being tested to enhance social skills. Patients with an autism spectrum disorder were more able to perceive emotions of others and to respond more appropriately.²⁶ Oxytocin has long been associated with bonding and is believed to enhance mothering skills. It is naturally present in both sexes, but levels are higher in women, which may in part explain the lower rate of autism spectrum disorders in females.²⁷

HEALTH CARE REQUIRES SPECIAL CONSIDERATIONS

Medical care for patients with Asperger syndrome is enhanced by understanding the patient’s experience. Adults, in particular, may have learned to suppress symptoms of Asperger syndrome to better function in society but still experience stress in situations in which others would not. Patients with Asperger syndrome may struggle with social interactions during medical examinations or procedures, and clinicians may find interaction with the patient challenging.

It is important for health care providers to be calm and patient and to understand that anxiety may prevent people with Asperger syndrome from making eye contact. The clinician should confirm that a patient is engaged but should avoid seeming pushy or invasive.

When anxious, patients may employ strange gestures that they find soothing, such as flapping the hands, rocking, or cracking the knuckles. It is usually easier to allow them to continue unless the activity hinders the examination or treatment.

Patients are likely to respond better to direct requests than to subtle questions: eg, “Open your mouth, please” instead of “Could you open your mouth?” Using clear, specific language and avoiding metaphors, irony, and nonverbal communication are best. It is important to explicitly ask for everything needed, as patients may not volunteer information and may have trouble articulating what they are thinking or feeling. While educating patients about their health needs, physicians may need to reiterate guidance several times or approach the same topic from different angles in order for the patient to accept a concern.

All actions, especially touching the patient, should be explained clearly beforehand. If possible, the doctor should demonstrate using visuals or on his or her own body if appropriate. For invasive procedures, anesthetizing the local area is recommended.

People with Asperger syndrome often rely heavily on a regular routine to maintain a sense of organization. By interrupting this routine, a doctor’s visit can induce anxiety. Waiting also increases anxiety, so scheduling patients with Asperger syndrome either first or last in the day may help.

Hypersensitivity poses challenges

Many people with Asperger syndrome have abnormal sensitivity to stimuli, with differences in pain sensation and hearing perhaps most prominent. Loud noises, such as beeping equipment, whirring fans, or buzzing lights may be distressful and should be reduced if possible. Patients may also be strongly affected by bright lights or scents such as perfumes.

Patients may also have an altered sense of taste, with consequences that go beyond simple “picky eating.” Patients should be asked about unusual eating patterns, diets, or food aversions. People with autism spectrum disorders often do not consume adequate vitamin C because of an aversion to fruits and vegetables. Vitamin deficiency may have originated in infancy but may not be identified or treated until adulthood.²⁸

The sense of touch may be intensified, causing patients to be extremely ticklish; they may actually prefer to be touched more firmly. When it is necessary to make physical contact with patients, it will make the process easier if the physician determines their comfort level and finds ways to help them endure the experience with the least amount of discomfort.

Some patients with impaired sensory expression may have a high tolerance for extreme temperatures and pain, leading to delay in seeking aid.²⁹ Patients may downgrade pain levels, masking the severity of an illness or injury.

Transition from pediatric to adult care

Pediatrics is often a warm environment in which children develop a trusting relationship with their care providers. The transition to adult care can be daunting for patients with Asperger syndrome and their families, and many postpone the change for as long as possible.

Although time-consuming, a collaborative effort between the pediatric and adult care teams can dramatically smooth the transition. It can help to have a familiar person from the pediatric team, such as a nurse, be present at the initial interaction with the new adult care team. Both teams should be familiar with the other’s clinical practices and be aware of the patient’s stressors and ways to ameliorate them.³⁰

THE SEARCH FOR A CAUSE CONTINUES

Numerous studies are attempting to understand the anatomic and physiologic causes of autism spectrum disorders, and to find effective treatments and improve the quality of life.

Prenatal factors implicated

Several recent studies have focused on environmental factors during pregnancy as risk factors for autism spectrum disorder. Selective serotonin reuptake inhibitors were found to increase the risk,³¹ but the severity of the mother’s depressive illness must be considered before counseling against using these drugs. Older maternal or paternal age was also found to increase the risk of an autism spectrum disorder.³² Recent research indicates that older fathers are in particular more likely to have children with disorders such as autism because of an increase in random mutations associated with advanced age.³³

Maternal illness during pregnancy is also associated. Preliminary studies found an increased risk of autism if the mother had had a prenatal viral infection.³⁴ A more recent study found that untreated fever during pregnancy rather than a specific viral infection is more strongly linked.³⁵

Maternal antibodies have been implicated as well. One review found that psoriasis is the only maternal autoimmune condition significantly associated with the development of an autism spectrum disorder.³⁶ Elevated levels of antibodies against the fetal brain have been found in mothers with autistic children.³⁷ One study found that autistic children and their siblings have elevated antibrain antibodies in distinct brain regions, including the caudate nucleus, putamen, prefrontal cortex, cerebellum, and cingulate gyrus (why the siblings are spared from having the disorder is unclear).³⁸ Some have questioned whether a child’s own immune system might even be involved.³⁹

Functional magnetic resonance imaging (fMRI) has been used to investigate impaired social interaction, specific deficits of facial perception and recognition, sensory processing, working memory, and “theory of mind.” Hypoactivation, hyperactivation, and decreased functional connectivity have been observed depending on the mental processes evaluated.⁴⁰

When undergoing facial perception tasks, subjects with autism spectrum disorders exhibit hypoactivation in the lateral aspect of the middle region of the fusiform gyrus, responsible for face identification. But they have significant activation of the limbic system, specifically the amygdala, during facial recognition. Hypoactivity in the fusiform gyrus is observed when trying to identify faces or read facial expressions.^41,42 This cluster of findings helps explain misinterpretations, misidentification, and heightened affect.

A hallmark characteristic of autism is the difficulty patients have in determining intentions and interpreting others’ behavior, thoughts, or emotions. Studies of people with autism spectrum disorders show that areas often responsible for “sensitivity to others” are hypoactive.⁴³ There is also diminished activation in the medial cingulate cortex, normally activated when these people are asked to think about themselves and who they are.⁴⁴

The resting state in the brains of people with autism spectrum disorders is abnormally activated.⁴⁵ They are often particularly good at attention to detail but challenged in integrating information needed for general executive functioning. Impaired sensory processing makes it difficult for them to simultaneously interpret multiple sources of sensory input.⁴⁶

Perhaps some of the most exciting fMRI news comes from infant studies. Radical and axial diffusivity and fractional anisotropy techniques demonstrate differences in the brains of infants 6 to 24 months old, before symptoms of autism spectrum disorders are observed. It is hoped that early intervention could come into play before the syndrome develops fully.⁴⁷

The synthesis of input of social and emotional cues is sometimes referred to in the literature as “theory of mind.” It is impaired in Asperger syndrome,⁴⁸ as manifested by a lack of empathy and by challenges in perceiving others’ thoughts and feelings. The basis of impairment may be related to abnormalities in the amygdala.⁴⁹ Normal awareness involves the integration of multiple neural networks in the anterior paracingulate cortex, the superior temporal sulci, and the temporal poles bilaterally, but different regions appear to be used in patients with Asperger syndrome.⁵⁰ A small series of five case studies using positron emission tomography indicated that the left prefrontal cortex was the primary location for theory of mind in Asperger syndrome.⁵¹

Epilepsy, gastrointestinal problems, and sleep disturbances are associated

About 25% of people with autism spectrum disorders have epilepsy vs 2% to 3% in the general population. Asperger syndrome is associated with a much lower but still elevated risk of 4% to 6%.^47,52

Gastrointestinal complaints, most often constipation or chronic diarrhea, are much more common in children with autism spectrum disorders than in the general population. Preliminary data showed that children with an autism spectrum disorder have a 42% rate of gastrointestinal problems vs 12% in unaffected siblings. There is also a correlation between the severity of gastrointestinal problems and severity of autistic symptoms.⁵³

Research is ongoing to determine the prevalence of insomnia or interrupted sleep in those with autism spectrum disorders.^54–56 Changes in sleep architecture can explain nighttime activity.

NONTRADITIONAL CONSIDERATIONS

Dietary treatment: Mixed findings

A popular hypothesis is that adherence to a gluten-free or casein-free diet can reduce symptoms of autism spectrum disorders. Preliminary reports identified several cases of children showing improvement.⁵⁷ However, this has not been replicated, and more studies refute benefits of these diets.⁵⁸

Essential nutritional needs should be met with any diet, whether it is designed to reduce symptoms or not. Patients with autism spectrum disorders may have strong food aversions, and dietary supplements of vitamins and minerals may be required.

Vaccines do not cause autism

Despite popular concern, recent research indicates that vaccines do not cause autism. Thimerosal, a mercury-based preservative used in childhood vaccines, was at one time implicated as a risk factor for autism spectrum disorders. The US Centers for Disease Control and Prevention (CDC) issued a precaution against using thimerosal-containing vaccines while testing was done to determine the effects on neuropsychological development.⁵⁹ The CDC study as well as newer studies did not demonstrate that exposure to mercury causes these neuropsychological concerns, but researchers have continued to study the subject.^60–62 The original study implicating thimerosal was disproven as scientifically unsound and fraught with conflict of interest and legal concerns. It has since been retracted, and its findings have been completely discredited.⁶³

Other areas of research

Current research is exploring the higher prevalence of autism spectrum disorders in particular families.^64–66 Autism and autism spectrum disorders may be caused by hundreds of simultaneous gene alterations or may develop as a result of reduced gene expression in two areas of the cerebral cortex where higher-order processing occurs, in the frontal and temporal lobes.⁶⁷

Although genetic theories of autism predominate, a 2011 project suggests that environment is also important. A study of twins found that genetics accounted for 40% or less of cases of autism spectrum disorder, with at least 55% of cases being attributable to environmental factors.⁶⁸

In 1944, Hans Asperger described a subset of children who exhibited “a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest, and clumsy movements.”¹

In recent years, Asperger syndrome has become increasingly recognized in the medical community and by the general public. It has been popularized in the media in John Elder Robison’s bestselling book, Look Me in the Eye; with the television character Sheldon Cooper in The Big Bang Theory; and in the 2009 film, Adam, a romantic comedy with the title character accurately portraying a young man with Asperger syndrome.

See related editorial

In this article, we discuss the causes and characteristics of Asperger syndrome, with special focus on adults: how it presents, how to treat it, and how to enhance the delivery of care.

PREVALENCE SEEMS TO BE INCREASING

One in 88 children is diagnosed with an autism spectrum disorder, and the rates of Asperger syndrome and other autism spectrum disorders appear to be increasing.² Whether this increase is the result of more thorough assessment and identification or of environmental changes is hotly debated.³ The rise began before the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified to simplify diagnosis.⁴ Asperger syndrome affects males three to four times more often than females.⁵ For most patients, the effects persist throughout life.

BEHAVIORAL IMPAIRMENTS CHARACTERIZE THE SYNDROME

Poor social skills are a hallmark

People with Asperger syndrome struggle with social interaction and face challenges in forming and maintaining relationships. They tend to have less eye contact (often the first indicator), smiling, animated speech, and physical communication such as hand gestures. They tend not to solicit another’s attention to something they themselves find interesting. They often lack social and emotional reciprocity and have difficulty understanding another person’s thoughts or feelings,⁶ and they have marked difficulty reading social cues. Some adults may appear rigid, selfish, or narrow-minded.

Sometimes behavior is in the normal range but is out of context for a particular situation.⁷ For example, a preprofessional student with Asperger syndrome might walk into a psychiatric evaluation to assess fitness for duty and take a seat cross-legged on the floor and have a snack. Poor grooming inappropriate for the occasion may also be observed, such as showing up for a formal photo with unkempt hair and in a stained shirt that is half tucked in.

Many adults with autism spectrum disorders are oblivious to their social reputation.⁸ They are often unaware that their behavior is out of place and only learn that it is not normal when they are told. Others recognize that they have trouble empathizing with or understanding the perspectives of others, but they are at a loss as to how to improve. The syndrome has a tremendous impact on broader aspects of life, such as employment, functional independence, relationships, and social networks.

Other odd behaviors are common

Repetitive behaviors. Many patients with Asperger syndrome have repetitive behaviors, which can manifest as repeating phrases or expressions, attempting to imitate others, and rocking. They tend to follow routines, do not enjoy spontaneity, and are more inflexible and uncomfortable when their planned regimen is altered.

Gait or balance issues may be observed on physical examination.⁹ Uncoordinated motion and clumsiness are common,¹⁰ and some patients may have a bouncy, stilted gait or may walk on their toes, although the latter is more common in children than adults. Many patients have illegible handwriting.¹¹

Fixations. Many Asperger patients have unusual and intense obsessions with subjects like numbers, dates, or aerodynamics of planes. Children with such fascinations are described as “little professors” or as having “geek syndrome.”¹² Certain obsessions often continue into adulthood, although one area of interest may fade and another may take over. Such “expertise” in adults may gain them respect, even though they may seem very odd in other ways.

Lack of boundaries. Patients with Asperger syndrome tend to have poor spatial awareness and to be unaware of physical boundaries, standing too close for others’ comfort or unusually far away. Lack of boundaries may extend beyond the physical, as patients may inappropriately help themselves to food or use an item belonging to another without invitation, being unaware that the behavior may be intrusive or inappropriate.

BEHAVIORAL ASSESSMENTS HELP MAKE DIAGNOSIS

Asperger syndrome is most often diagnosed in early childhood, although it may remain undiagnosed into adulthood. Coexisting depression, attention deficit hyperactivity disorder, or anxiety disorders are also often present.

Establishing the diagnosis is aided by information from family members and others who interact with the patient, from the observations of trained professionals, and from self-reported data. However, self-reported assessments are not always reliable, because the syndrome can affect insight.

The most common assessment tool for autism spectrum disorders is the Autism Diagnostic Interview-Revised (ADI-R),¹³ a battery of tests given in a structured interview to identify and quantify symptoms, determine where a patient falls on the autism spectrum,¹⁴ and point toward interventions. The ADI-R also organizes critical developmental history to evaluate if something else is present, such as prodromal schizophrenia. Although the ADI-R can be very useful in the diagnostic process, it is based on parental reporting, which is neither always available nor fully reliable.

A specific diagnostic tool for adults is the Adult Asperger Assessment.¹⁵ Patients are asked to complete two screening questionnaires that gauge cognitive function and gather information about thinking, processing, and behavior.

Table 1 lists the criteria for Asperger syndrome from the DSM Fourth Edition, Text Revision (DSM-IV-TR).¹⁶ Asperger syndrome differs from general autism in that it is not associated with language delay. In addition, patients with Asperger syndrome usually have average or above-average IQ scores.¹⁷ Still, determining whether a patient has Asperger syndrome or high-functioning autism is sometimes challenging.⁶

In DSM-V, Asperger syndrome will be subsumed under autism spectrum disorder

In 2013, the DSM-V will replace the DSMIV-TR and will combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise classified into a single diagnosis: autism spectrum disorder. The new system uses two instead of the previous three clusters of core symptoms, centered on “social reciprocity and communication” in one arm and “restricted interests and repetitive behavior” in the other.¹⁸ There will be less emphasis on play and imagination than in the past. Some authors suggest adding sensory criteria, particularly reduced pain and increased hearing sensitivity.¹⁹

The proposed system is sensitive and specific for autism spectrum disorders, allows early diagnosis, and indicates degree of severity.²⁰ It is hoped that the new system, which accounts for the range and severity of symptoms, should help physicians refer patients to the correct level of treatment.

On the other hand, it may be difficult to think of the three disorders as a single diagnosis. Asperger syndrome manifests in distinct ways, and clear behavioral criteria for diagnosis can be invaluable in helping people with the syndrome. Also, the public may continue to refer to it as Asperger syndrome, and parents and patients may feel uncomfortable having it considered to be the same diagnosis as autism.

BEHAVIORAL THERAPY CAN HELP ACHIEVE INDEPENDENCE

Although there is no cure for Asperger syndrome, various interventions can dramatically improve quality of life and independence. The health care team may include a primary care physician, psychologist, psychiatrist, neurologist, and speech therapist.

Behavioral therapies can help patients with Asperger syndrome learn skills to reduce their symptoms. Occupational and physical therapy can improve dexterity, fluidity, and coordination. Desensitization training may help patients adapt to uncomfortable sights, sounds, or smells that may arise. This can be critical in a job situation. For example, while an average person exposed to a foul odor in public is likely to react tactfully, a person with Asperger syndrome may scream loudly, make inappropriate comments, or run from the room. Social training, especially targeted to the workplace, can provide strategies for promoting typical behaviors and be key to maximizing functional independence.

Speech therapists can teach patients how to sound more relaxed and help them master the natural give-and-take of conversational exchange. Psychotherapy can provide a safe place to work on anxiety, express emotions, and manage restricted interests or repeated behaviors. Group therapy or social training can be a venue for learning improved interactions.

Living independently can be very challenging, and patients with Asperger syndrome may need functional independence training to help with a variety of skills, from handling finances to organizing the home.

Improving quality of life includes determining the best learning environments from childhood into college years and beyond.^21–23 Socialization can be enhanced with additional social support at home or on campus, through family interactions and collaborative learning, and by teaching empathy.²⁴ Vocational training can be extremely useful.

DRUG THERAPY MAY HAVE A ROLE

Medications are not usually prescribed unless depression or anxiety is also present, but they may also help manage irritability, anger, stereotypical mannerisms, and disturbing movements. Fluoxetine (Prozac) helps reduce repetitive behaviors in adults with Asperger syndrome. Propranolol (Inderal), a well-known antihypertensive, is also used for performance anxiety and improves word fluency, understanding of verbal communication, and verbal problem-solving in patients with an autism spectrum disorder.²⁵

Giving oxytocin (Pitocin) intranasally in a spray formulation is currently being tested to enhance social skills. Patients with an autism spectrum disorder were more able to perceive emotions of others and to respond more appropriately.²⁶ Oxytocin has long been associated with bonding and is believed to enhance mothering skills. It is naturally present in both sexes, but levels are higher in women, which may in part explain the lower rate of autism spectrum disorders in females.²⁷

HEALTH CARE REQUIRES SPECIAL CONSIDERATIONS

Medical care for patients with Asperger syndrome is enhanced by understanding the patient’s experience. Adults, in particular, may have learned to suppress symptoms of Asperger syndrome to better function in society but still experience stress in situations in which others would not. Patients with Asperger syndrome may struggle with social interactions during medical examinations or procedures, and clinicians may find interaction with the patient challenging.

It is important for health care providers to be calm and patient and to understand that anxiety may prevent people with Asperger syndrome from making eye contact. The clinician should confirm that a patient is engaged but should avoid seeming pushy or invasive.

When anxious, patients may employ strange gestures that they find soothing, such as flapping the hands, rocking, or cracking the knuckles. It is usually easier to allow them to continue unless the activity hinders the examination or treatment.

Patients are likely to respond better to direct requests than to subtle questions: eg, “Open your mouth, please” instead of “Could you open your mouth?” Using clear, specific language and avoiding metaphors, irony, and nonverbal communication are best. It is important to explicitly ask for everything needed, as patients may not volunteer information and may have trouble articulating what they are thinking or feeling. While educating patients about their health needs, physicians may need to reiterate guidance several times or approach the same topic from different angles in order for the patient to accept a concern.

All actions, especially touching the patient, should be explained clearly beforehand. If possible, the doctor should demonstrate using visuals or on his or her own body if appropriate. For invasive procedures, anesthetizing the local area is recommended.

People with Asperger syndrome often rely heavily on a regular routine to maintain a sense of organization. By interrupting this routine, a doctor’s visit can induce anxiety. Waiting also increases anxiety, so scheduling patients with Asperger syndrome either first or last in the day may help.

Hypersensitivity poses challenges

Many people with Asperger syndrome have abnormal sensitivity to stimuli, with differences in pain sensation and hearing perhaps most prominent. Loud noises, such as beeping equipment, whirring fans, or buzzing lights may be distressful and should be reduced if possible. Patients may also be strongly affected by bright lights or scents such as perfumes.

Patients may also have an altered sense of taste, with consequences that go beyond simple “picky eating.” Patients should be asked about unusual eating patterns, diets, or food aversions. People with autism spectrum disorders often do not consume adequate vitamin C because of an aversion to fruits and vegetables. Vitamin deficiency may have originated in infancy but may not be identified or treated until adulthood.²⁸

The sense of touch may be intensified, causing patients to be extremely ticklish; they may actually prefer to be touched more firmly. When it is necessary to make physical contact with patients, it will make the process easier if the physician determines their comfort level and finds ways to help them endure the experience with the least amount of discomfort.

Some patients with impaired sensory expression may have a high tolerance for extreme temperatures and pain, leading to delay in seeking aid.²⁹ Patients may downgrade pain levels, masking the severity of an illness or injury.

Transition from pediatric to adult care

Pediatrics is often a warm environment in which children develop a trusting relationship with their care providers. The transition to adult care can be daunting for patients with Asperger syndrome and their families, and many postpone the change for as long as possible.

Although time-consuming, a collaborative effort between the pediatric and adult care teams can dramatically smooth the transition. It can help to have a familiar person from the pediatric team, such as a nurse, be present at the initial interaction with the new adult care team. Both teams should be familiar with the other’s clinical practices and be aware of the patient’s stressors and ways to ameliorate them.³⁰

THE SEARCH FOR A CAUSE CONTINUES

Numerous studies are attempting to understand the anatomic and physiologic causes of autism spectrum disorders, and to find effective treatments and improve the quality of life.

Prenatal factors implicated

Several recent studies have focused on environmental factors during pregnancy as risk factors for autism spectrum disorder. Selective serotonin reuptake inhibitors were found to increase the risk,³¹ but the severity of the mother’s depressive illness must be considered before counseling against using these drugs. Older maternal or paternal age was also found to increase the risk of an autism spectrum disorder.³² Recent research indicates that older fathers are in particular more likely to have children with disorders such as autism because of an increase in random mutations associated with advanced age.³³

Maternal illness during pregnancy is also associated. Preliminary studies found an increased risk of autism if the mother had had a prenatal viral infection.³⁴ A more recent study found that untreated fever during pregnancy rather than a specific viral infection is more strongly linked.³⁵

Maternal antibodies have been implicated as well. One review found that psoriasis is the only maternal autoimmune condition significantly associated with the development of an autism spectrum disorder.³⁶ Elevated levels of antibodies against the fetal brain have been found in mothers with autistic children.³⁷ One study found that autistic children and their siblings have elevated antibrain antibodies in distinct brain regions, including the caudate nucleus, putamen, prefrontal cortex, cerebellum, and cingulate gyrus (why the siblings are spared from having the disorder is unclear).³⁸ Some have questioned whether a child’s own immune system might even be involved.³⁹

Functional magnetic resonance imaging (fMRI) has been used to investigate impaired social interaction, specific deficits of facial perception and recognition, sensory processing, working memory, and “theory of mind.” Hypoactivation, hyperactivation, and decreased functional connectivity have been observed depending on the mental processes evaluated.⁴⁰

When undergoing facial perception tasks, subjects with autism spectrum disorders exhibit hypoactivation in the lateral aspect of the middle region of the fusiform gyrus, responsible for face identification. But they have significant activation of the limbic system, specifically the amygdala, during facial recognition. Hypoactivity in the fusiform gyrus is observed when trying to identify faces or read facial expressions.^41,42 This cluster of findings helps explain misinterpretations, misidentification, and heightened affect.

A hallmark characteristic of autism is the difficulty patients have in determining intentions and interpreting others’ behavior, thoughts, or emotions. Studies of people with autism spectrum disorders show that areas often responsible for “sensitivity to others” are hypoactive.⁴³ There is also diminished activation in the medial cingulate cortex, normally activated when these people are asked to think about themselves and who they are.⁴⁴

The resting state in the brains of people with autism spectrum disorders is abnormally activated.⁴⁵ They are often particularly good at attention to detail but challenged in integrating information needed for general executive functioning. Impaired sensory processing makes it difficult for them to simultaneously interpret multiple sources of sensory input.⁴⁶

Perhaps some of the most exciting fMRI news comes from infant studies. Radical and axial diffusivity and fractional anisotropy techniques demonstrate differences in the brains of infants 6 to 24 months old, before symptoms of autism spectrum disorders are observed. It is hoped that early intervention could come into play before the syndrome develops fully.⁴⁷

The synthesis of input of social and emotional cues is sometimes referred to in the literature as “theory of mind.” It is impaired in Asperger syndrome,⁴⁸ as manifested by a lack of empathy and by challenges in perceiving others’ thoughts and feelings. The basis of impairment may be related to abnormalities in the amygdala.⁴⁹ Normal awareness involves the integration of multiple neural networks in the anterior paracingulate cortex, the superior temporal sulci, and the temporal poles bilaterally, but different regions appear to be used in patients with Asperger syndrome.⁵⁰ A small series of five case studies using positron emission tomography indicated that the left prefrontal cortex was the primary location for theory of mind in Asperger syndrome.⁵¹

Epilepsy, gastrointestinal problems, and sleep disturbances are associated

About 25% of people with autism spectrum disorders have epilepsy vs 2% to 3% in the general population. Asperger syndrome is associated with a much lower but still elevated risk of 4% to 6%.^47,52

Gastrointestinal complaints, most often constipation or chronic diarrhea, are much more common in children with autism spectrum disorders than in the general population. Preliminary data showed that children with an autism spectrum disorder have a 42% rate of gastrointestinal problems vs 12% in unaffected siblings. There is also a correlation between the severity of gastrointestinal problems and severity of autistic symptoms.⁵³

Research is ongoing to determine the prevalence of insomnia or interrupted sleep in those with autism spectrum disorders.^54–56 Changes in sleep architecture can explain nighttime activity.

NONTRADITIONAL CONSIDERATIONS

Dietary treatment: Mixed findings

A popular hypothesis is that adherence to a gluten-free or casein-free diet can reduce symptoms of autism spectrum disorders. Preliminary reports identified several cases of children showing improvement.⁵⁷ However, this has not been replicated, and more studies refute benefits of these diets.⁵⁸

Essential nutritional needs should be met with any diet, whether it is designed to reduce symptoms or not. Patients with autism spectrum disorders may have strong food aversions, and dietary supplements of vitamins and minerals may be required.

Vaccines do not cause autism

Despite popular concern, recent research indicates that vaccines do not cause autism. Thimerosal, a mercury-based preservative used in childhood vaccines, was at one time implicated as a risk factor for autism spectrum disorders. The US Centers for Disease Control and Prevention (CDC) issued a precaution against using thimerosal-containing vaccines while testing was done to determine the effects on neuropsychological development.⁵⁹ The CDC study as well as newer studies did not demonstrate that exposure to mercury causes these neuropsychological concerns, but researchers have continued to study the subject.^60–62 The original study implicating thimerosal was disproven as scientifically unsound and fraught with conflict of interest and legal concerns. It has since been retracted, and its findings have been completely discredited.⁶³

Other areas of research

Current research is exploring the higher prevalence of autism spectrum disorders in particular families.^64–66 Autism and autism spectrum disorders may be caused by hundreds of simultaneous gene alterations or may develop as a result of reduced gene expression in two areas of the cerebral cortex where higher-order processing occurs, in the frontal and temporal lobes.⁶⁷

Although genetic theories of autism predominate, a 2011 project suggests that environment is also important. A study of twins found that genetics accounted for 40% or less of cases of autism spectrum disorder, with at least 55% of cases being attributable to environmental factors.⁶⁸

A majority of patients with mild traumatic brain injury (mTBI) have evidence of chronic traumatic encephalopathy (CTE), according to research published in the online December 2 Brain. Of 85 participants with a history of mTBI, 68 (80%) showed postmortem evidence of the degenerative brain disease. The persons with CTE were all males ages 17 to 98, most of whom were athletes and military veterans. The researchers used a four-stage system to classify CTE, and symptoms ranged from headache and concentration difficulties in stage one to dementia, aggression, and difficulty with words in stage four. Among American football players, stage of CTE correlated with increased duration of football play, survival after football, and age of death. “There is an ordered and predictable progression of hyperphosphorylated tau abnormalities through the nervous system in CTE that occurs in conjunction with widespread axonal disruption and loss,” the researchers said.
Persons who experience traumatic brain injury (TBI) and have also been exposed to the pesticide paraquat have triple the risk of developing Parkinson’s disease, according to research published in the November 13 Neurology. From 2001 to 2011, investigators examined 357 persons with idiopathic Parkinson’s disease and 754 population controls. A validated geographic information system based on records of pesticide application was used to assess paraquat exposure, while TBI was assessed through self-report of all head injuries that involved loss of consciousness for greater than five minutes. According to the researchers, exposure to paraquat and TBI each moderately increase the risk of Parkinson’s disease. However, the risk of developing Parkinson’s disease was threefold higher in study participants with both TBI and exposure to paraquat than in participants exposed to neither risk factor, the investigators said.
Preterm-born children have a significantly reduced capacity for cortical neuroplasticity, which affects learning and memory, researchers reported in the November 14 Journal of Neuroscience. The investigators used a noninvasive magnetic brain stimulation technique to induce long-term depressionlike neuroplasticity in groups of adolescents born after early preterm, late preterm, and term gestations. “Compared with term-born adolescents, both early and late preterm adolescents had reduced long-term depressionlike neuroplasticity in response to brain stimulation that was also associated with low salivary cortisol levels,” said the study authors, adding that these findings may show a potential mechanistic link between the brain physiology of preterm birth and behavioral deficits in learning and memory. Altered hypothalamic-pituitary-adrenal axis function may modulate the altered neuroplasticity and may offer options for therapeutic interventions, the researchers concluded.
MRI scans show that patients with mild traumatic brain injury (mTBI) have abnormal default-mode network connectivity patterns, researchers reported in the December Radiology. The study used resting-state functional MRI to characterize the default-mode network and included 18 healthy controls and 23 patients with mTBI who had post-traumatic symptoms less than two months after injury. Compared with controls, patients with mTBI showed significantly reduced connectivity in the posterior cingulate complex and parietal regions, which correlated positively with neurocognitive dysfunction. Patients with mTBI also showed increased frontal connectivity around the medial prefrontal cortex, which correlated with post-traumatic symptoms such as depression, anxiety, fatigue, and postconcussion syndrome. According to the researchers, the results may “provide insight into how neuronal communication and information integration are disrupted among default-mode network key structures after mild head injury.”

Increased concentration of phosphorylated neurofilament heavy subunit (pNF-H) in the plasma, serum, and CSF of patients with amyotrophic lateral sclerosis (ALS) may be associated with faster disease progression, according to research published in the online October 31 Journal of Neurology, Neurosurgery & Psychiatry. Investigators measured pNF-H concentration in the plasma and CSF of patients with ALS from the Mayo Clinic Florida and Emory University, as well as plasma from an earlier pilot study of 20 patients with ALS. Analysis showed that higher levels of pNF-H in plasma, serum, and CSF were linked with greater decline for ALS patients. The researchers also noted that patients with bulbar onset might have higher pNF-H concentration in plasma than those with spinal onset, though the results require confirmation. “These data support further study of pNF-H in CSF, serum, and plasma as a potential ALS biomarker,” the study authors said.
Paralyzed dogs who received intraspinal transplantation of cells derived from olfactory mucosal cultures regained some movement, researchers reported in the November Brain. The investigators conducted a randomized, double-blind clinical trial in which dogs with severe chronic thoracolumbar spinal injuries received an injection of either intraspinal autologous cells derived from olfactory mucosal cultures or cell transport medium alone. Dogs who received the olfactory mucosal transplants showed significantly better fore–hind coordination than those who received only the cell transport medium. “We conclude that intraspinal olfactory mucosal cell transplantation improves communication across the damaged region of the injured spinal cord, even in chronically injured individuals. However, we find no evidence for concomitant improvement in long tract function,” the researchers said.
Suvorexant, an orexin receptor antagonist, may offer a novel approach to treating insomnia, researchers reported in the December Neurology. In a randomized, double-blind, placebo-controlled study that took place during two periods of four weeks, patients received 10 mg, 20 mg, 40 mg, or 80 mg of suvorexant in one period and placebo in the other period. Coprimary end points were sleep efficiency on night one and at the end of week four. Patients receiving suvorexant showed significant dose-related improvements on both of the primary end points compared with those receiving placebo. “Dose-related effects were also observed for sleep induction (latency to persistent sleep) and maintenance (wake after sleep onset). Suvorexant was generally well tolerated,” the researchers said.
Persons born in April have significantly more risk of developing multiple sclerosis (MS) than those born in October and November, according to research published in the online November 14 Journal of Neurology, Neurosurgery & Psychiatry. The study was a meta-analysis of previously published data on month of birth of 151,978 patients with MS. According to the researchers, the month of birth effect is “likely to be due to ultraviolet light exposure and maternal vitamin D levels.” In a separate study published in the November 20 Neurology, investigators observed an association between high levels of vitamin D in the years prior to disease onset and a decreased risk of MS. However, there was no association between gestational levels of vitamin D and MS risk in the offspring. Decreasing levels of vitamin D in the population might help explain the increase in MS cases suggested from epidemiologic studies, the study authors said.
Mutations of the immune system gene TREM2 may be linked to an increased risk of Alzheimer’s disease, researchers reported in two studies in the online November 14 New England Journal of Medicine. In one study, investigators analyzed the genetic variability in TREM2 and performed a meta-analysis on imputed data for the TREM2 variant rs75932628, which is predicted to cause a R47H substitution. The R47H mutation was highly significantly associated with Alzheimer’s disease, said the authors. In the second study, researchers examined genome sequences of 2,261 Icelanders and found that the TREM2 mutation rs75932628-T conferred a significant risk of Alzheimer’s disease (odds ratio, 2.92). “Given the reported anti-inflammatory role of TREM2 in the brain, the R47H substitution may lead to an increased predisposition to Alzheimer’s disease through impaired containment of inflammatory processes,” the investigators concluded.
Exposure to traffic-related air pollution during pregnancy and the first year of life is associated with autism, according to a study published in the online November Archives of General Psychiatry. Researchers conducted a population-based case-control study that included data from 279 children with autism and 245 control children with typical development. Compared with controls, those with autism were more likely to live in areas with the highest quartile of exposure to traffic-related air pollution during gestation and during the first year of life. Exposure to particulate matter and nitrogen dioxide were also linked with autism. “Further epidemiological and toxicological examinations of likely biological pathways will help determine whether these associations are causal,” the researchers concluded.
Consumption of fish and long-chain omega 3 fatty acids may moderately reduce cerebrovascular risk, but fish oil supplements may not have the same beneficial effect, according to research published in the October 30 BMJ. The systemic review and meta-analysis examined 26 prospective cohort studies and 12 randomized controlled trials with aggregate data on 794,000 participants and 34,817 cerebrovascular outcomes. Results showed that persons who ate two to four servings of fish per week and those who ate five or more servings a week had a lower risk of cerebrovascular disease, compared with persons who ate one serving a week. However, no association was observed between risk for cerebrovascular disease and long-chain omega 3 fatty acids measured as circulating biomarkers in observational studies or supplements in primary and secondary prevention trials.
Depression is the most important factor affecting the health status of patients with Parkinson’s disease, according to early findings released as part of the Parkinson’s Outcome Project, a longitudinal study examining which treatments produce the best outcomes. The study, which began in 2009, includes data from more than 5,500 patients with Parkinson’s disease. Based on this research, the National Parkinson Foundation recommends screening patients for depression at least once a year and encouraging patients to discuss any mood change with a health care professional, particularly the physician treating them for Parkinson’s disease. Patients may also benefit from bringing a family member to doctor’s appointments and asking the family member to share any changes in the patient’s mood.                          

A majority of patients with mild traumatic brain injury (mTBI) have evidence of chronic traumatic encephalopathy (CTE), according to research published in the online December 2 Brain. Of 85 participants with a history of mTBI, 68 (80%) showed postmortem evidence of the degenerative brain disease. The persons with CTE were all males ages 17 to 98, most of whom were athletes and military veterans. The researchers used a four-stage system to classify CTE, and symptoms ranged from headache and concentration difficulties in stage one to dementia, aggression, and difficulty with words in stage four. Among American football players, stage of CTE correlated with increased duration of football play, survival after football, and age of death. “There is an ordered and predictable progression of hyperphosphorylated tau abnormalities through the nervous system in CTE that occurs in conjunction with widespread axonal disruption and loss,” the researchers said.
Persons who experience traumatic brain injury (TBI) and have also been exposed to the pesticide paraquat have triple the risk of developing Parkinson’s disease, according to research published in the November 13 Neurology. From 2001 to 2011, investigators examined 357 persons with idiopathic Parkinson’s disease and 754 population controls. A validated geographic information system based on records of pesticide application was used to assess paraquat exposure, while TBI was assessed through self-report of all head injuries that involved loss of consciousness for greater than five minutes. According to the researchers, exposure to paraquat and TBI each moderately increase the risk of Parkinson’s disease. However, the risk of developing Parkinson’s disease was threefold higher in study participants with both TBI and exposure to paraquat than in participants exposed to neither risk factor, the investigators said.
Preterm-born children have a significantly reduced capacity for cortical neuroplasticity, which affects learning and memory, researchers reported in the November 14 Journal of Neuroscience. The investigators used a noninvasive magnetic brain stimulation technique to induce long-term depressionlike neuroplasticity in groups of adolescents born after early preterm, late preterm, and term gestations. “Compared with term-born adolescents, both early and late preterm adolescents had reduced long-term depressionlike neuroplasticity in response to brain stimulation that was also associated with low salivary cortisol levels,” said the study authors, adding that these findings may show a potential mechanistic link between the brain physiology of preterm birth and behavioral deficits in learning and memory. Altered hypothalamic-pituitary-adrenal axis function may modulate the altered neuroplasticity and may offer options for therapeutic interventions, the researchers concluded.
MRI scans show that patients with mild traumatic brain injury (mTBI) have abnormal default-mode network connectivity patterns, researchers reported in the December Radiology. The study used resting-state functional MRI to characterize the default-mode network and included 18 healthy controls and 23 patients with mTBI who had post-traumatic symptoms less than two months after injury. Compared with controls, patients with mTBI showed significantly reduced connectivity in the posterior cingulate complex and parietal regions, which correlated positively with neurocognitive dysfunction. Patients with mTBI also showed increased frontal connectivity around the medial prefrontal cortex, which correlated with post-traumatic symptoms such as depression, anxiety, fatigue, and postconcussion syndrome. According to the researchers, the results may “provide insight into how neuronal communication and information integration are disrupted among default-mode network key structures after mild head injury.”

Increased concentration of phosphorylated neurofilament heavy subunit (pNF-H) in the plasma, serum, and CSF of patients with amyotrophic lateral sclerosis (ALS) may be associated with faster disease progression, according to research published in the online October 31 Journal of Neurology, Neurosurgery & Psychiatry. Investigators measured pNF-H concentration in the plasma and CSF of patients with ALS from the Mayo Clinic Florida and Emory University, as well as plasma from an earlier pilot study of 20 patients with ALS. Analysis showed that higher levels of pNF-H in plasma, serum, and CSF were linked with greater decline for ALS patients. The researchers also noted that patients with bulbar onset might have higher pNF-H concentration in plasma than those with spinal onset, though the results require confirmation. “These data support further study of pNF-H in CSF, serum, and plasma as a potential ALS biomarker,” the study authors said.
Paralyzed dogs who received intraspinal transplantation of cells derived from olfactory mucosal cultures regained some movement, researchers reported in the November Brain. The investigators conducted a randomized, double-blind clinical trial in which dogs with severe chronic thoracolumbar spinal injuries received an injection of either intraspinal autologous cells derived from olfactory mucosal cultures or cell transport medium alone. Dogs who received the olfactory mucosal transplants showed significantly better fore–hind coordination than those who received only the cell transport medium. “We conclude that intraspinal olfactory mucosal cell transplantation improves communication across the damaged region of the injured spinal cord, even in chronically injured individuals. However, we find no evidence for concomitant improvement in long tract function,” the researchers said.
Suvorexant, an orexin receptor antagonist, may offer a novel approach to treating insomnia, researchers reported in the December Neurology. In a randomized, double-blind, placebo-controlled study that took place during two periods of four weeks, patients received 10 mg, 20 mg, 40 mg, or 80 mg of suvorexant in one period and placebo in the other period. Coprimary end points were sleep efficiency on night one and at the end of week four. Patients receiving suvorexant showed significant dose-related improvements on both of the primary end points compared with those receiving placebo. “Dose-related effects were also observed for sleep induction (latency to persistent sleep) and maintenance (wake after sleep onset). Suvorexant was generally well tolerated,” the researchers said.
Persons born in April have significantly more risk of developing multiple sclerosis (MS) than those born in October and November, according to research published in the online November 14 Journal of Neurology, Neurosurgery & Psychiatry. The study was a meta-analysis of previously published data on month of birth of 151,978 patients with MS. According to the researchers, the month of birth effect is “likely to be due to ultraviolet light exposure and maternal vitamin D levels.” In a separate study published in the November 20 Neurology, investigators observed an association between high levels of vitamin D in the years prior to disease onset and a decreased risk of MS. However, there was no association between gestational levels of vitamin D and MS risk in the offspring. Decreasing levels of vitamin D in the population might help explain the increase in MS cases suggested from epidemiologic studies, the study authors said.
Mutations of the immune system gene TREM2 may be linked to an increased risk of Alzheimer’s disease, researchers reported in two studies in the online November 14 New England Journal of Medicine. In one study, investigators analyzed the genetic variability in TREM2 and performed a meta-analysis on imputed data for the TREM2 variant rs75932628, which is predicted to cause a R47H substitution. The R47H mutation was highly significantly associated with Alzheimer’s disease, said the authors. In the second study, researchers examined genome sequences of 2,261 Icelanders and found that the TREM2 mutation rs75932628-T conferred a significant risk of Alzheimer’s disease (odds ratio, 2.92). “Given the reported anti-inflammatory role of TREM2 in the brain, the R47H substitution may lead to an increased predisposition to Alzheimer’s disease through impaired containment of inflammatory processes,” the investigators concluded.
Exposure to traffic-related air pollution during pregnancy and the first year of life is associated with autism, according to a study published in the online November Archives of General Psychiatry. Researchers conducted a population-based case-control study that included data from 279 children with autism and 245 control children with typical development. Compared with controls, those with autism were more likely to live in areas with the highest quartile of exposure to traffic-related air pollution during gestation and during the first year of life. Exposure to particulate matter and nitrogen dioxide were also linked with autism. “Further epidemiological and toxicological examinations of likely biological pathways will help determine whether these associations are causal,” the researchers concluded.
Consumption of fish and long-chain omega 3 fatty acids may moderately reduce cerebrovascular risk, but fish oil supplements may not have the same beneficial effect, according to research published in the October 30 BMJ. The systemic review and meta-analysis examined 26 prospective cohort studies and 12 randomized controlled trials with aggregate data on 794,000 participants and 34,817 cerebrovascular outcomes. Results showed that persons who ate two to four servings of fish per week and those who ate five or more servings a week had a lower risk of cerebrovascular disease, compared with persons who ate one serving a week. However, no association was observed between risk for cerebrovascular disease and long-chain omega 3 fatty acids measured as circulating biomarkers in observational studies or supplements in primary and secondary prevention trials.
Depression is the most important factor affecting the health status of patients with Parkinson’s disease, according to early findings released as part of the Parkinson’s Outcome Project, a longitudinal study examining which treatments produce the best outcomes. The study, which began in 2009, includes data from more than 5,500 patients with Parkinson’s disease. Based on this research, the National Parkinson Foundation recommends screening patients for depression at least once a year and encouraging patients to discuss any mood change with a health care professional, particularly the physician treating them for Parkinson’s disease. Patients may also benefit from bringing a family member to doctor’s appointments and asking the family member to share any changes in the patient’s mood.                          

A majority of patients with mild traumatic brain injury (mTBI) have evidence of chronic traumatic encephalopathy (CTE), according to research published in the online December 2 Brain. Of 85 participants with a history of mTBI, 68 (80%) showed postmortem evidence of the degenerative brain disease. The persons with CTE were all males ages 17 to 98, most of whom were athletes and military veterans. The researchers used a four-stage system to classify CTE, and symptoms ranged from headache and concentration difficulties in stage one to dementia, aggression, and difficulty with words in stage four. Among American football players, stage of CTE correlated with increased duration of football play, survival after football, and age of death. “There is an ordered and predictable progression of hyperphosphorylated tau abnormalities through the nervous system in CTE that occurs in conjunction with widespread axonal disruption and loss,” the researchers said.
Persons who experience traumatic brain injury (TBI) and have also been exposed to the pesticide paraquat have triple the risk of developing Parkinson’s disease, according to research published in the November 13 Neurology. From 2001 to 2011, investigators examined 357 persons with idiopathic Parkinson’s disease and 754 population controls. A validated geographic information system based on records of pesticide application was used to assess paraquat exposure, while TBI was assessed through self-report of all head injuries that involved loss of consciousness for greater than five minutes. According to the researchers, exposure to paraquat and TBI each moderately increase the risk of Parkinson’s disease. However, the risk of developing Parkinson’s disease was threefold higher in study participants with both TBI and exposure to paraquat than in participants exposed to neither risk factor, the investigators said.
Preterm-born children have a significantly reduced capacity for cortical neuroplasticity, which affects learning and memory, researchers reported in the November 14 Journal of Neuroscience. The investigators used a noninvasive magnetic brain stimulation technique to induce long-term depressionlike neuroplasticity in groups of adolescents born after early preterm, late preterm, and term gestations. “Compared with term-born adolescents, both early and late preterm adolescents had reduced long-term depressionlike neuroplasticity in response to brain stimulation that was also associated with low salivary cortisol levels,” said the study authors, adding that these findings may show a potential mechanistic link between the brain physiology of preterm birth and behavioral deficits in learning and memory. Altered hypothalamic-pituitary-adrenal axis function may modulate the altered neuroplasticity and may offer options for therapeutic interventions, the researchers concluded.
MRI scans show that patients with mild traumatic brain injury (mTBI) have abnormal default-mode network connectivity patterns, researchers reported in the December Radiology. The study used resting-state functional MRI to characterize the default-mode network and included 18 healthy controls and 23 patients with mTBI who had post-traumatic symptoms less than two months after injury. Compared with controls, patients with mTBI showed significantly reduced connectivity in the posterior cingulate complex and parietal regions, which correlated positively with neurocognitive dysfunction. Patients with mTBI also showed increased frontal connectivity around the medial prefrontal cortex, which correlated with post-traumatic symptoms such as depression, anxiety, fatigue, and postconcussion syndrome. According to the researchers, the results may “provide insight into how neuronal communication and information integration are disrupted among default-mode network key structures after mild head injury.”

Increased concentration of phosphorylated neurofilament heavy subunit (pNF-H) in the plasma, serum, and CSF of patients with amyotrophic lateral sclerosis (ALS) may be associated with faster disease progression, according to research published in the online October 31 Journal of Neurology, Neurosurgery & Psychiatry. Investigators measured pNF-H concentration in the plasma and CSF of patients with ALS from the Mayo Clinic Florida and Emory University, as well as plasma from an earlier pilot study of 20 patients with ALS. Analysis showed that higher levels of pNF-H in plasma, serum, and CSF were linked with greater decline for ALS patients. The researchers also noted that patients with bulbar onset might have higher pNF-H concentration in plasma than those with spinal onset, though the results require confirmation. “These data support further study of pNF-H in CSF, serum, and plasma as a potential ALS biomarker,” the study authors said.
Paralyzed dogs who received intraspinal transplantation of cells derived from olfactory mucosal cultures regained some movement, researchers reported in the November Brain. The investigators conducted a randomized, double-blind clinical trial in which dogs with severe chronic thoracolumbar spinal injuries received an injection of either intraspinal autologous cells derived from olfactory mucosal cultures or cell transport medium alone. Dogs who received the olfactory mucosal transplants showed significantly better fore–hind coordination than those who received only the cell transport medium. “We conclude that intraspinal olfactory mucosal cell transplantation improves communication across the damaged region of the injured spinal cord, even in chronically injured individuals. However, we find no evidence for concomitant improvement in long tract function,” the researchers said.
Suvorexant, an orexin receptor antagonist, may offer a novel approach to treating insomnia, researchers reported in the December Neurology. In a randomized, double-blind, placebo-controlled study that took place during two periods of four weeks, patients received 10 mg, 20 mg, 40 mg, or 80 mg of suvorexant in one period and placebo in the other period. Coprimary end points were sleep efficiency on night one and at the end of week four. Patients receiving suvorexant showed significant dose-related improvements on both of the primary end points compared with those receiving placebo. “Dose-related effects were also observed for sleep induction (latency to persistent sleep) and maintenance (wake after sleep onset). Suvorexant was generally well tolerated,” the researchers said.
Persons born in April have significantly more risk of developing multiple sclerosis (MS) than those born in October and November, according to research published in the online November 14 Journal of Neurology, Neurosurgery & Psychiatry. The study was a meta-analysis of previously published data on month of birth of 151,978 patients with MS. According to the researchers, the month of birth effect is “likely to be due to ultraviolet light exposure and maternal vitamin D levels.” In a separate study published in the November 20 Neurology, investigators observed an association between high levels of vitamin D in the years prior to disease onset and a decreased risk of MS. However, there was no association between gestational levels of vitamin D and MS risk in the offspring. Decreasing levels of vitamin D in the population might help explain the increase in MS cases suggested from epidemiologic studies, the study authors said.
Mutations of the immune system gene TREM2 may be linked to an increased risk of Alzheimer’s disease, researchers reported in two studies in the online November 14 New England Journal of Medicine. In one study, investigators analyzed the genetic variability in TREM2 and performed a meta-analysis on imputed data for the TREM2 variant rs75932628, which is predicted to cause a R47H substitution. The R47H mutation was highly significantly associated with Alzheimer’s disease, said the authors. In the second study, researchers examined genome sequences of 2,261 Icelanders and found that the TREM2 mutation rs75932628-T conferred a significant risk of Alzheimer’s disease (odds ratio, 2.92). “Given the reported anti-inflammatory role of TREM2 in the brain, the R47H substitution may lead to an increased predisposition to Alzheimer’s disease through impaired containment of inflammatory processes,” the investigators concluded.
Exposure to traffic-related air pollution during pregnancy and the first year of life is associated with autism, according to a study published in the online November Archives of General Psychiatry. Researchers conducted a population-based case-control study that included data from 279 children with autism and 245 control children with typical development. Compared with controls, those with autism were more likely to live in areas with the highest quartile of exposure to traffic-related air pollution during gestation and during the first year of life. Exposure to particulate matter and nitrogen dioxide were also linked with autism. “Further epidemiological and toxicological examinations of likely biological pathways will help determine whether these associations are causal,” the researchers concluded.
Consumption of fish and long-chain omega 3 fatty acids may moderately reduce cerebrovascular risk, but fish oil supplements may not have the same beneficial effect, according to research published in the October 30 BMJ. The systemic review and meta-analysis examined 26 prospective cohort studies and 12 randomized controlled trials with aggregate data on 794,000 participants and 34,817 cerebrovascular outcomes. Results showed that persons who ate two to four servings of fish per week and those who ate five or more servings a week had a lower risk of cerebrovascular disease, compared with persons who ate one serving a week. However, no association was observed between risk for cerebrovascular disease and long-chain omega 3 fatty acids measured as circulating biomarkers in observational studies or supplements in primary and secondary prevention trials.
Depression is the most important factor affecting the health status of patients with Parkinson’s disease, according to early findings released as part of the Parkinson’s Outcome Project, a longitudinal study examining which treatments produce the best outcomes. The study, which began in 2009, includes data from more than 5,500 patients with Parkinson’s disease. Based on this research, the National Parkinson Foundation recommends screening patients for depression at least once a year and encouraging patients to discuss any mood change with a health care professional, particularly the physician treating them for Parkinson’s disease. Patients may also benefit from bringing a family member to doctor’s appointments and asking the family member to share any changes in the patient’s mood.                          

On an autumn day, a 38-year-old woman with a history of asthma presented to the emergency department (ED) with the chief complaint of shortness of breath (SOB). The patient described her SOB as sudden in onset and not relieved by use of her albuterol inhaler; hence the ED visit.

She denied any chest pain, palpitations, dizziness, orthopnea, upper respiratory tract infection, cough, wheezing, fever or chills, headache, vision changes, body aches, sick contacts, or pets at home. She said she uses her albuterol inhaler as needed, and that she had used it that day for the first time in “a few months.” She denied any history of intubation or steroid use. Additionally, she had not been seen by a primary care provider in years.

The woman, a native of Ghana, had been living in the United States for many years. She denied any recent travel or exposure to toxic chemicals; any use of tobacco, alcohol, or illicit drugs; or any history of sexually transmitted disease.

The patient was afebrile (temperature, 98.6°F), with a respiratory rate of 20 breaths/min; blood pressure, 144/69 mm Hg; and ventricular rate, 125 beats/min. On physical examination, her extraocular movements were intact; pupils were equal, round, reactive to light and accommodation; and sclera were nonicteric. The patient’s head was normocephalic and atraumatic, and the neck was supple with normal range of motion and no jugular venous distension or lymphadenopathy. Her mucous membranes were moist with no pharyngeal erythema or exudates. Cardiovascular examination, including ECG, revealed tachycardia but no murmurs or gallops.

While being evaluated in the ED, the patient became tachypneic and began to experience respiratory distress. She was intubated for airway protection, at which time she developed pulseless electrical activity (PEA), with 30 beats/min. She responded to atropine and epinephrine injections. A repeat ECG showed sinus tachycardia and right atrial enlargement with right-axis deviation. Chest x-ray (see Figure 1) showed no consolidation, pleural effusion, or pneumothorax.

Results from the patient’s lab work are shown in the table, above. Negative results were reported for a urine pregnancy test.

Since there was no clear etiology for the patient’s PEA, she underwent pan-culturing, with the following tests ordered: HIV antibody testing, immunovirology for influenza A and B viruses, and urine toxicology. Doppler ultrasound of the bilateral lower extremities was also ordered, in addition to chest CT and transthoracic and transesophageal echocardiography (TTE and TEE, respectively). The patient was intubated and transferred to the medical ICU for further management.

The differential diagnosis included cardiac tamponade, acute MI, acute pulmonary embolus (PE), tension pneumothorax, hypovolemia, and asthma exacerbated by viral or bacterial infection.^1,2 Although the case patient presented with PEA, she did not have the presenting signs of cardiac tamponade known as Beck’s triad: hypotension, jugular venous distension, and muffled heart sounds.³ TTE showed an ejection fraction of 65% and grade 2 diastolic dysfunction but no pericardial effusions (which accumulate rapidly in the patient with cardiac tamponade, resulting from fluid buildup in the pericardial layers),⁴ and TEE showed no atrial thrombi (which can masquerade as cardiac tamponade⁵). The patient had no signs of trauma and denied any history of malignancy (both potential causes of cardiac tamponade). Chest x-ray showed normal heart size and no pneumothorax, consolidations, or pleural effusions.^4,6-8 Thus, the diagnosis of cardiac tamponade was ruled out.

Common presenting symptoms of acute MI include sudden-onset chest pain, SOB, palpitations, dizziness, nausea, and/or vomiting. Women may experience less dramatic symptoms—often little more than SOB and fatigue.⁹ According to a 2000 consensus document from a joint European Society of Cardiology/American College of Cardiology committee¹⁰ in which MI was redefined, the diagnosis of MI relies on a rise in cardiac troponin levels, typical MI symptoms, and changes in ECG showing pathological Q waves or ST elevation or depression. The case patient’s troponin I level was less than 0.02 ng/mL, and ECG did not reveal Q waves or ST-T wave changes; additionally, since the patient had no chest pain, palpitations, diaphoresis, nausea, or vomiting, acute MI was ruled out.

Blood clots capable of blocking the pulmonary artery usually originate in the deep veins of the lower extremities.¹¹ Three main factors, called Virchow’s triad, are known to contribute to these deep vein thromboses (DVTs): venous stasis, endothelial injury, and a hypercoagulability state.^12,13 The patient had denied any trauma, recent travel, history of malignancy, or use of tobacco or oral contraceptives, and the result of her urine pregnancy test was negative. Even though the patient presented with tachypnea and acute SOB, with ECG showing right-axis deviation and tachycardia (common presenting signs and symptoms for PE), her chest CT showed no evidence of PE (see Figure 2); additionally, Doppler ultrasound of the bilateral lower extremities revealed no DVTs. Thus, PE was also excluded.

Tension pneumothorax was also ruled out, as chest x-ray showed neither mediastinal shift nor tracheal deviation, and the patient had denied any trauma. Laboratory analyses did not indicate hyponatremia, and the patient’s hemoglobin and hematocrit were satisfactory. She was tachycardic on admission, but her blood pressure was stable. As the patient denied any use of vasodilators or diuretics, hypovolemia was ruled out.

Patients experiencing asthma exacerbation can present with acute SOB, which usually resolves following use of IV steroids, nebulizer therapy, and inhaler treatments. Despite being administered IV methylprednisolone and magnesium sulfate in the ED, the patient experienced PEA and respiratory distress and required intubation for airway protection.

The HIV test was nonreactive, and blood and urine cultures did not show any growth. Results of tests for Legionella urinary antigen and Streptococcus pneumoniae antigen were negative. Sputum culture showed normal flora. Immunovirology testing, however, was positive for both influenza A and B antigens.

Chest X-ray showed no acute pulmonary pathology, nor did chest CT show any central, interlobar, or segmental embolism or mediastinal lymphadenopathy. It was determined that the patient’s acute SOB might represent asthma exacerbation secondary to influenza viral infection. Her PEA was attributed to possible acute pericarditis secondary to concomitant influenza A and B viral infection.

DISCUSSION
Currently, the CDC recognizes three types of influenza virus: A, B, and C.¹⁴ Only influenza A viruses are further classified into subtypes, based on the presence of surface proteins called hemagglutinin (HA) or neuraminidase (NA) glycoproteins. Humans can be infected by influenza A subtypes H1N1 and H3N2.¹⁴ Influenza B viruses, found mostly in humans, are associated with significant morbidity and mortality.

Influenza A and B viruses are further classified into strains that change with each flu season—thus, the need to update vaccinations against influenza A and B each year. No vaccination exists against influenza C virus, which is known to cause only mild illness in humans.¹⁵

In patients with asthma (as in the case patient), chronic bronchitis, or emphysema, infection with the influenza virus can manifest with SOB, in addition to the more common symptoms of fever, sore throat, headache, rhinorrhea, chills, muscle aches, and general discomfort.¹⁶ Patients with coronary artery disease, congestive heart failure (CHF), and/or a history of smoking may experience more severe symptoms and increased risk for influenza-associated mortality than do other patients.^17,18

Rare cardiac complications of influenza infections are myocarditis and benign acute pericarditis; myocarditis can progress to CHF and death.^19,20 A case of acute myopericarditis was reported by Proby et al²¹ in a patient with acute influenza A infection who developed pericardial effusions, myositis, tamponade, and pleurisy. That patient recovered after pericardiocentesis and administration of inotropic drugs.

In the literature, a few cases of acute pericarditis have been reported in association with administration of the influenza vaccination.^22,23

In the case patient, the diagnosis of influenza A and B was made following testing of nasal and nasopharyngeal swabs with an immunochromatographic assay that uses highly sensitive monoclonal antibodies to detect influenza A and B nucleoprotein antigens.^24,25

According to reports in the literature, two-thirds of cases of acute pericarditis are caused by infection, most commonly viral infection (including influenza virus, adenovirus, enterovirus, cytomegalovirus, hepatitis B virus, and herpes simplex virus).^26,27 Other etiologies for acute pericarditis are autoimmune (accounting for less than 10% of cases) and neoplastic conditions (5% to 7% of cases).²⁶

PATIENT OUTCOME
Consultation with an infectious disease specialist was obtained. The patient was placed under droplet isolation precautions and was started on a nebulizer, IV steroid treatments, and oseltamivir 75 mg by mouth every 12 hours. She was transferred to a medical floor, where she completed a five-day course of oseltamivir.

As a result of timely intervention, the patient was discharged in stable condition on a therapeutic regimen that included albuterol, fluticasone, and salmeterol inhalation, in addition to tapered-dose steroids. She was advised to follow up with her primary care provider and at the pulmonary clinic.

CONCLUSION
To our knowledge, this is the first reported case of acute pericarditis in a patient with concomitant acute infections with influenza A and B. According to conclusions reached in recent literature, further research is needed to explain the pathophysiology of influenza viral infections, associated cardiovascular morbidity and mortality, and the degree to which these can be prevented by influenza vaccination.^1,28 Also to be pursued through research is a better understanding of the morbidity and mortality associated with influenza viruses, especially in children and in adults affected by asthma, cardiac disease, and/or obesity.

REFERENCES
1. Finelli L, Chaves SS. Influenza and acute myocardial infarction. J Infect Dis. 2011;203(12):

1701-1704.

2. Steiger HV, Rimbach K, Müller E, Breitkreutz R. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Eur J Emerg Med. 2009;16(2): 103-105.

3. Goodman A, Perera P, Mailhot T, Mandavia D. The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade.

J Emerg Trauma Shock. 2012;5(1):72-75.

4. Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007;27(6):1595-1610.

5. Papanagnou D, Stone MB. Massive right atrial thrombus masquerading as cardiac tamponade. Acad Emerg Med. 2010;17(2):E11.

6. Saito Y, Donohue A, Attai S, et al. The syndrome of cardiac tamponade with “small” pericardial effusion. Echocardiography. 2008;25(3): 321-327.

7. Lin E, Boire A, Hemmige V, et al. Cardiac tamponade mimicking tuberculous pericarditis as the initial presentation of chronic lymphocytic leukemia in a 58-year-old woman: a case report. J Med Case Rep. 2010;4:246.

8. Meniconi A, Attenhofer Jost CH, Jenni R. How to survive myocardial rupture after myocardial infarction. Heart. 2000;84(5):552.

9. Kosuge M, Kimura K, Ishikawa T, et al. Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circ J. 2006;70(3):222-226.

10. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36(3):959-969.

11. Goldhaber SZ. Deep venous thrombosis and pulmonary thromboembolism. In: Fauci AS, Braunwald E, Kasper DL, et al. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill Medical; 2008:1651–1657.

12. Brooks EG, Trotman W, Wadsworth MP, et al. Valves of the deep venous system: an overlooked risk factor. Blood. 2009;114(6):1276-1279.

13. Kyrle PA, Eichinger S. Is Virchow’s triad complete? Blood. 2009;114(6):1138-1139.

14. CDC. Seasonal influenza (flu): types of influenza viruses (2012). www.cdc.gov/flu/about/viruses/types.htm. Accessed October 24, 2012.

15. CDC. Seasonal influenza (flu)(2012). www.cdc .gov/flu. Accessed October 24, 2012.

16. Eccles R. Understanding the symptoms of the common cold and influenza. Lancet Infect Dis. 2005;5(11):718-725.

17. Angelo SJ, Marshall PS, Chrissoheris MP, Chaves AM. Clinical characteristics associated with poor outcome in patients acutely infected with Influenza A. Conn Med. 2004;68(4):199-205.

18. Murin S, Bilello K. Respiratory tract infections: another reason not to smoke. Cleve Clin J Med. 2005;72(10):916-920.

19. Ray CG, Icenogle TB, Minnich LL, et al. The use of intravenous ribavirin to treat influenza virus–associated acute myocarditis. J Infect Dis. 1989; 159(5):829-836.

20. Fairley CK, Ryan M, Wall PG, Weinberg J. The organism reported to cause infective myocarditis and pericarditis in England and Wales. J Infect. 1996;32(3):223-225.

21. Proby CM, Hackett D, Gupta S, Cox TM. Acute myopericarditis in influenza A infection. Q J Med. 1986;60(233):887-892.

22. Streifler JJ, Dux S, Garty M, Rosenfeld JB. Recurrent pericarditis: a rare complication of influenza vaccination. Br Med J (Clin Res Ed). 1981; 283(6290):526-527.

23. Desson JF, Leprévost M, Vabret F, Davy A. Acute benign pericarditis after anti-influenza vaccination [in French]. Presse Med. 1997;26 (9):415.

24. BinaxNOW® Influenza A&B Test Kit (product instructions). www.diagnosticsdirect2u.com/images/PDF/Binax%20Now%20416-022%20PPI .pdf. Accessed October 24, 2012.

25. 510(k) Substantial Equivalence Determination Decision Summary [BinaxNow® Influenza A & B Test] (2009). www.accessdata.fda.gov/cdrh_docs/reviews/K062109.pdf. Accessed October 24, 2012.

26. Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation. 2010;121(7):916-928.

27. Maisch B, Seferovic PM, Ristic AD, et al; Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases: executive summary. Eur Heart J. 2004;25(7):587-610.

28. McCullers JA, Hayden FG. Fatal influenza B infections: time to reexamine influenza research priorities. J Infect Dis. 2012;205(6):870-872.

On an autumn day, a 38-year-old woman with a history of asthma presented to the emergency department (ED) with the chief complaint of shortness of breath (SOB). The patient described her SOB as sudden in onset and not relieved by use of her albuterol inhaler; hence the ED visit.

She denied any chest pain, palpitations, dizziness, orthopnea, upper respiratory tract infection, cough, wheezing, fever or chills, headache, vision changes, body aches, sick contacts, or pets at home. She said she uses her albuterol inhaler as needed, and that she had used it that day for the first time in “a few months.” She denied any history of intubation or steroid use. Additionally, she had not been seen by a primary care provider in years.

The woman, a native of Ghana, had been living in the United States for many years. She denied any recent travel or exposure to toxic chemicals; any use of tobacco, alcohol, or illicit drugs; or any history of sexually transmitted disease.

The patient was afebrile (temperature, 98.6°F), with a respiratory rate of 20 breaths/min; blood pressure, 144/69 mm Hg; and ventricular rate, 125 beats/min. On physical examination, her extraocular movements were intact; pupils were equal, round, reactive to light and accommodation; and sclera were nonicteric. The patient’s head was normocephalic and atraumatic, and the neck was supple with normal range of motion and no jugular venous distension or lymphadenopathy. Her mucous membranes were moist with no pharyngeal erythema or exudates. Cardiovascular examination, including ECG, revealed tachycardia but no murmurs or gallops.

While being evaluated in the ED, the patient became tachypneic and began to experience respiratory distress. She was intubated for airway protection, at which time she developed pulseless electrical activity (PEA), with 30 beats/min. She responded to atropine and epinephrine injections. A repeat ECG showed sinus tachycardia and right atrial enlargement with right-axis deviation. Chest x-ray (see Figure 1) showed no consolidation, pleural effusion, or pneumothorax.

Results from the patient’s lab work are shown in the table, above. Negative results were reported for a urine pregnancy test.

Since there was no clear etiology for the patient’s PEA, she underwent pan-culturing, with the following tests ordered: HIV antibody testing, immunovirology for influenza A and B viruses, and urine toxicology. Doppler ultrasound of the bilateral lower extremities was also ordered, in addition to chest CT and transthoracic and transesophageal echocardiography (TTE and TEE, respectively). The patient was intubated and transferred to the medical ICU for further management.

The differential diagnosis included cardiac tamponade, acute MI, acute pulmonary embolus (PE), tension pneumothorax, hypovolemia, and asthma exacerbated by viral or bacterial infection.^1,2 Although the case patient presented with PEA, she did not have the presenting signs of cardiac tamponade known as Beck’s triad: hypotension, jugular venous distension, and muffled heart sounds.³ TTE showed an ejection fraction of 65% and grade 2 diastolic dysfunction but no pericardial effusions (which accumulate rapidly in the patient with cardiac tamponade, resulting from fluid buildup in the pericardial layers),⁴ and TEE showed no atrial thrombi (which can masquerade as cardiac tamponade⁵). The patient had no signs of trauma and denied any history of malignancy (both potential causes of cardiac tamponade). Chest x-ray showed normal heart size and no pneumothorax, consolidations, or pleural effusions.^4,6-8 Thus, the diagnosis of cardiac tamponade was ruled out.

Common presenting symptoms of acute MI include sudden-onset chest pain, SOB, palpitations, dizziness, nausea, and/or vomiting. Women may experience less dramatic symptoms—often little more than SOB and fatigue.⁹ According to a 2000 consensus document from a joint European Society of Cardiology/American College of Cardiology committee¹⁰ in which MI was redefined, the diagnosis of MI relies on a rise in cardiac troponin levels, typical MI symptoms, and changes in ECG showing pathological Q waves or ST elevation or depression. The case patient’s troponin I level was less than 0.02 ng/mL, and ECG did not reveal Q waves or ST-T wave changes; additionally, since the patient had no chest pain, palpitations, diaphoresis, nausea, or vomiting, acute MI was ruled out.

Blood clots capable of blocking the pulmonary artery usually originate in the deep veins of the lower extremities.¹¹ Three main factors, called Virchow’s triad, are known to contribute to these deep vein thromboses (DVTs): venous stasis, endothelial injury, and a hypercoagulability state.^12,13 The patient had denied any trauma, recent travel, history of malignancy, or use of tobacco or oral contraceptives, and the result of her urine pregnancy test was negative. Even though the patient presented with tachypnea and acute SOB, with ECG showing right-axis deviation and tachycardia (common presenting signs and symptoms for PE), her chest CT showed no evidence of PE (see Figure 2); additionally, Doppler ultrasound of the bilateral lower extremities revealed no DVTs. Thus, PE was also excluded.

Tension pneumothorax was also ruled out, as chest x-ray showed neither mediastinal shift nor tracheal deviation, and the patient had denied any trauma. Laboratory analyses did not indicate hyponatremia, and the patient’s hemoglobin and hematocrit were satisfactory. She was tachycardic on admission, but her blood pressure was stable. As the patient denied any use of vasodilators or diuretics, hypovolemia was ruled out.

Patients experiencing asthma exacerbation can present with acute SOB, which usually resolves following use of IV steroids, nebulizer therapy, and inhaler treatments. Despite being administered IV methylprednisolone and magnesium sulfate in the ED, the patient experienced PEA and respiratory distress and required intubation for airway protection.

The HIV test was nonreactive, and blood and urine cultures did not show any growth. Results of tests for Legionella urinary antigen and Streptococcus pneumoniae antigen were negative. Sputum culture showed normal flora. Immunovirology testing, however, was positive for both influenza A and B antigens.

Chest X-ray showed no acute pulmonary pathology, nor did chest CT show any central, interlobar, or segmental embolism or mediastinal lymphadenopathy. It was determined that the patient’s acute SOB might represent asthma exacerbation secondary to influenza viral infection. Her PEA was attributed to possible acute pericarditis secondary to concomitant influenza A and B viral infection.

DISCUSSION
Currently, the CDC recognizes three types of influenza virus: A, B, and C.¹⁴ Only influenza A viruses are further classified into subtypes, based on the presence of surface proteins called hemagglutinin (HA) or neuraminidase (NA) glycoproteins. Humans can be infected by influenza A subtypes H1N1 and H3N2.¹⁴ Influenza B viruses, found mostly in humans, are associated with significant morbidity and mortality.

Influenza A and B viruses are further classified into strains that change with each flu season—thus, the need to update vaccinations against influenza A and B each year. No vaccination exists against influenza C virus, which is known to cause only mild illness in humans.¹⁵

In patients with asthma (as in the case patient), chronic bronchitis, or emphysema, infection with the influenza virus can manifest with SOB, in addition to the more common symptoms of fever, sore throat, headache, rhinorrhea, chills, muscle aches, and general discomfort.¹⁶ Patients with coronary artery disease, congestive heart failure (CHF), and/or a history of smoking may experience more severe symptoms and increased risk for influenza-associated mortality than do other patients.^17,18

Rare cardiac complications of influenza infections are myocarditis and benign acute pericarditis; myocarditis can progress to CHF and death.^19,20 A case of acute myopericarditis was reported by Proby et al²¹ in a patient with acute influenza A infection who developed pericardial effusions, myositis, tamponade, and pleurisy. That patient recovered after pericardiocentesis and administration of inotropic drugs.

In the literature, a few cases of acute pericarditis have been reported in association with administration of the influenza vaccination.^22,23

In the case patient, the diagnosis of influenza A and B was made following testing of nasal and nasopharyngeal swabs with an immunochromatographic assay that uses highly sensitive monoclonal antibodies to detect influenza A and B nucleoprotein antigens.^24,25

According to reports in the literature, two-thirds of cases of acute pericarditis are caused by infection, most commonly viral infection (including influenza virus, adenovirus, enterovirus, cytomegalovirus, hepatitis B virus, and herpes simplex virus).^26,27 Other etiologies for acute pericarditis are autoimmune (accounting for less than 10% of cases) and neoplastic conditions (5% to 7% of cases).²⁶

PATIENT OUTCOME
Consultation with an infectious disease specialist was obtained. The patient was placed under droplet isolation precautions and was started on a nebulizer, IV steroid treatments, and oseltamivir 75 mg by mouth every 12 hours. She was transferred to a medical floor, where she completed a five-day course of oseltamivir.

As a result of timely intervention, the patient was discharged in stable condition on a therapeutic regimen that included albuterol, fluticasone, and salmeterol inhalation, in addition to tapered-dose steroids. She was advised to follow up with her primary care provider and at the pulmonary clinic.

CONCLUSION
To our knowledge, this is the first reported case of acute pericarditis in a patient with concomitant acute infections with influenza A and B. According to conclusions reached in recent literature, further research is needed to explain the pathophysiology of influenza viral infections, associated cardiovascular morbidity and mortality, and the degree to which these can be prevented by influenza vaccination.^1,28 Also to be pursued through research is a better understanding of the morbidity and mortality associated with influenza viruses, especially in children and in adults affected by asthma, cardiac disease, and/or obesity.

REFERENCES
1. Finelli L, Chaves SS. Influenza and acute myocardial infarction. J Infect Dis. 2011;203(12):

1701-1704.

2. Steiger HV, Rimbach K, Müller E, Breitkreutz R. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Eur J Emerg Med. 2009;16(2): 103-105.

3. Goodman A, Perera P, Mailhot T, Mandavia D. The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade.

J Emerg Trauma Shock. 2012;5(1):72-75.

4. Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007;27(6):1595-1610.

5. Papanagnou D, Stone MB. Massive right atrial thrombus masquerading as cardiac tamponade. Acad Emerg Med. 2010;17(2):E11.

6. Saito Y, Donohue A, Attai S, et al. The syndrome of cardiac tamponade with “small” pericardial effusion. Echocardiography. 2008;25(3): 321-327.

7. Lin E, Boire A, Hemmige V, et al. Cardiac tamponade mimicking tuberculous pericarditis as the initial presentation of chronic lymphocytic leukemia in a 58-year-old woman: a case report. J Med Case Rep. 2010;4:246.

8. Meniconi A, Attenhofer Jost CH, Jenni R. How to survive myocardial rupture after myocardial infarction. Heart. 2000;84(5):552.

9. Kosuge M, Kimura K, Ishikawa T, et al. Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circ J. 2006;70(3):222-226.

10. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36(3):959-969.

11. Goldhaber SZ. Deep venous thrombosis and pulmonary thromboembolism. In: Fauci AS, Braunwald E, Kasper DL, et al. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill Medical; 2008:1651–1657.

12. Brooks EG, Trotman W, Wadsworth MP, et al. Valves of the deep venous system: an overlooked risk factor. Blood. 2009;114(6):1276-1279.

13. Kyrle PA, Eichinger S. Is Virchow’s triad complete? Blood. 2009;114(6):1138-1139.

14. CDC. Seasonal influenza (flu): types of influenza viruses (2012). www.cdc.gov/flu/about/viruses/types.htm. Accessed October 24, 2012.

15. CDC. Seasonal influenza (flu)(2012). www.cdc .gov/flu. Accessed October 24, 2012.

16. Eccles R. Understanding the symptoms of the common cold and influenza. Lancet Infect Dis. 2005;5(11):718-725.

17. Angelo SJ, Marshall PS, Chrissoheris MP, Chaves AM. Clinical characteristics associated with poor outcome in patients acutely infected with Influenza A. Conn Med. 2004;68(4):199-205.

18. Murin S, Bilello K. Respiratory tract infections: another reason not to smoke. Cleve Clin J Med. 2005;72(10):916-920.

19. Ray CG, Icenogle TB, Minnich LL, et al. The use of intravenous ribavirin to treat influenza virus–associated acute myocarditis. J Infect Dis. 1989; 159(5):829-836.

20. Fairley CK, Ryan M, Wall PG, Weinberg J. The organism reported to cause infective myocarditis and pericarditis in England and Wales. J Infect. 1996;32(3):223-225.

21. Proby CM, Hackett D, Gupta S, Cox TM. Acute myopericarditis in influenza A infection. Q J Med. 1986;60(233):887-892.

22. Streifler JJ, Dux S, Garty M, Rosenfeld JB. Recurrent pericarditis: a rare complication of influenza vaccination. Br Med J (Clin Res Ed). 1981; 283(6290):526-527.

23. Desson JF, Leprévost M, Vabret F, Davy A. Acute benign pericarditis after anti-influenza vaccination [in French]. Presse Med. 1997;26 (9):415.

24. BinaxNOW® Influenza A&B Test Kit (product instructions). www.diagnosticsdirect2u.com/images/PDF/Binax%20Now%20416-022%20PPI .pdf. Accessed October 24, 2012.

25. 510(k) Substantial Equivalence Determination Decision Summary [BinaxNow® Influenza A & B Test] (2009). www.accessdata.fda.gov/cdrh_docs/reviews/K062109.pdf. Accessed October 24, 2012.

26. Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation. 2010;121(7):916-928.

27. Maisch B, Seferovic PM, Ristic AD, et al; Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases: executive summary. Eur Heart J. 2004;25(7):587-610.

28. McCullers JA, Hayden FG. Fatal influenza B infections: time to reexamine influenza research priorities. J Infect Dis. 2012;205(6):870-872.

On an autumn day, a 38-year-old woman with a history of asthma presented to the emergency department (ED) with the chief complaint of shortness of breath (SOB). The patient described her SOB as sudden in onset and not relieved by use of her albuterol inhaler; hence the ED visit.

She denied any chest pain, palpitations, dizziness, orthopnea, upper respiratory tract infection, cough, wheezing, fever or chills, headache, vision changes, body aches, sick contacts, or pets at home. She said she uses her albuterol inhaler as needed, and that she had used it that day for the first time in “a few months.” She denied any history of intubation or steroid use. Additionally, she had not been seen by a primary care provider in years.

The woman, a native of Ghana, had been living in the United States for many years. She denied any recent travel or exposure to toxic chemicals; any use of tobacco, alcohol, or illicit drugs; or any history of sexually transmitted disease.

The patient was afebrile (temperature, 98.6°F), with a respiratory rate of 20 breaths/min; blood pressure, 144/69 mm Hg; and ventricular rate, 125 beats/min. On physical examination, her extraocular movements were intact; pupils were equal, round, reactive to light and accommodation; and sclera were nonicteric. The patient’s head was normocephalic and atraumatic, and the neck was supple with normal range of motion and no jugular venous distension or lymphadenopathy. Her mucous membranes were moist with no pharyngeal erythema or exudates. Cardiovascular examination, including ECG, revealed tachycardia but no murmurs or gallops.

While being evaluated in the ED, the patient became tachypneic and began to experience respiratory distress. She was intubated for airway protection, at which time she developed pulseless electrical activity (PEA), with 30 beats/min. She responded to atropine and epinephrine injections. A repeat ECG showed sinus tachycardia and right atrial enlargement with right-axis deviation. Chest x-ray (see Figure 1) showed no consolidation, pleural effusion, or pneumothorax.

Results from the patient’s lab work are shown in the table, above. Negative results were reported for a urine pregnancy test.

Since there was no clear etiology for the patient’s PEA, she underwent pan-culturing, with the following tests ordered: HIV antibody testing, immunovirology for influenza A and B viruses, and urine toxicology. Doppler ultrasound of the bilateral lower extremities was also ordered, in addition to chest CT and transthoracic and transesophageal echocardiography (TTE and TEE, respectively). The patient was intubated and transferred to the medical ICU for further management.

The differential diagnosis included cardiac tamponade, acute MI, acute pulmonary embolus (PE), tension pneumothorax, hypovolemia, and asthma exacerbated by viral or bacterial infection.^1,2 Although the case patient presented with PEA, she did not have the presenting signs of cardiac tamponade known as Beck’s triad: hypotension, jugular venous distension, and muffled heart sounds.³ TTE showed an ejection fraction of 65% and grade 2 diastolic dysfunction but no pericardial effusions (which accumulate rapidly in the patient with cardiac tamponade, resulting from fluid buildup in the pericardial layers),⁴ and TEE showed no atrial thrombi (which can masquerade as cardiac tamponade⁵). The patient had no signs of trauma and denied any history of malignancy (both potential causes of cardiac tamponade). Chest x-ray showed normal heart size and no pneumothorax, consolidations, or pleural effusions.^4,6-8 Thus, the diagnosis of cardiac tamponade was ruled out.

Common presenting symptoms of acute MI include sudden-onset chest pain, SOB, palpitations, dizziness, nausea, and/or vomiting. Women may experience less dramatic symptoms—often little more than SOB and fatigue.⁹ According to a 2000 consensus document from a joint European Society of Cardiology/American College of Cardiology committee¹⁰ in which MI was redefined, the diagnosis of MI relies on a rise in cardiac troponin levels, typical MI symptoms, and changes in ECG showing pathological Q waves or ST elevation or depression. The case patient’s troponin I level was less than 0.02 ng/mL, and ECG did not reveal Q waves or ST-T wave changes; additionally, since the patient had no chest pain, palpitations, diaphoresis, nausea, or vomiting, acute MI was ruled out.

Blood clots capable of blocking the pulmonary artery usually originate in the deep veins of the lower extremities.¹¹ Three main factors, called Virchow’s triad, are known to contribute to these deep vein thromboses (DVTs): venous stasis, endothelial injury, and a hypercoagulability state.^12,13 The patient had denied any trauma, recent travel, history of malignancy, or use of tobacco or oral contraceptives, and the result of her urine pregnancy test was negative. Even though the patient presented with tachypnea and acute SOB, with ECG showing right-axis deviation and tachycardia (common presenting signs and symptoms for PE), her chest CT showed no evidence of PE (see Figure 2); additionally, Doppler ultrasound of the bilateral lower extremities revealed no DVTs. Thus, PE was also excluded.

Tension pneumothorax was also ruled out, as chest x-ray showed neither mediastinal shift nor tracheal deviation, and the patient had denied any trauma. Laboratory analyses did not indicate hyponatremia, and the patient’s hemoglobin and hematocrit were satisfactory. She was tachycardic on admission, but her blood pressure was stable. As the patient denied any use of vasodilators or diuretics, hypovolemia was ruled out.

Patients experiencing asthma exacerbation can present with acute SOB, which usually resolves following use of IV steroids, nebulizer therapy, and inhaler treatments. Despite being administered IV methylprednisolone and magnesium sulfate in the ED, the patient experienced PEA and respiratory distress and required intubation for airway protection.

The HIV test was nonreactive, and blood and urine cultures did not show any growth. Results of tests for Legionella urinary antigen and Streptococcus pneumoniae antigen were negative. Sputum culture showed normal flora. Immunovirology testing, however, was positive for both influenza A and B antigens.

Chest X-ray showed no acute pulmonary pathology, nor did chest CT show any central, interlobar, or segmental embolism or mediastinal lymphadenopathy. It was determined that the patient’s acute SOB might represent asthma exacerbation secondary to influenza viral infection. Her PEA was attributed to possible acute pericarditis secondary to concomitant influenza A and B viral infection.

DISCUSSION
Currently, the CDC recognizes three types of influenza virus: A, B, and C.¹⁴ Only influenza A viruses are further classified into subtypes, based on the presence of surface proteins called hemagglutinin (HA) or neuraminidase (NA) glycoproteins. Humans can be infected by influenza A subtypes H1N1 and H3N2.¹⁴ Influenza B viruses, found mostly in humans, are associated with significant morbidity and mortality.

Influenza A and B viruses are further classified into strains that change with each flu season—thus, the need to update vaccinations against influenza A and B each year. No vaccination exists against influenza C virus, which is known to cause only mild illness in humans.¹⁵

In patients with asthma (as in the case patient), chronic bronchitis, or emphysema, infection with the influenza virus can manifest with SOB, in addition to the more common symptoms of fever, sore throat, headache, rhinorrhea, chills, muscle aches, and general discomfort.¹⁶ Patients with coronary artery disease, congestive heart failure (CHF), and/or a history of smoking may experience more severe symptoms and increased risk for influenza-associated mortality than do other patients.^17,18

Rare cardiac complications of influenza infections are myocarditis and benign acute pericarditis; myocarditis can progress to CHF and death.^19,20 A case of acute myopericarditis was reported by Proby et al²¹ in a patient with acute influenza A infection who developed pericardial effusions, myositis, tamponade, and pleurisy. That patient recovered after pericardiocentesis and administration of inotropic drugs.

In the literature, a few cases of acute pericarditis have been reported in association with administration of the influenza vaccination.^22,23

In the case patient, the diagnosis of influenza A and B was made following testing of nasal and nasopharyngeal swabs with an immunochromatographic assay that uses highly sensitive monoclonal antibodies to detect influenza A and B nucleoprotein antigens.^24,25

According to reports in the literature, two-thirds of cases of acute pericarditis are caused by infection, most commonly viral infection (including influenza virus, adenovirus, enterovirus, cytomegalovirus, hepatitis B virus, and herpes simplex virus).^26,27 Other etiologies for acute pericarditis are autoimmune (accounting for less than 10% of cases) and neoplastic conditions (5% to 7% of cases).²⁶

PATIENT OUTCOME
Consultation with an infectious disease specialist was obtained. The patient was placed under droplet isolation precautions and was started on a nebulizer, IV steroid treatments, and oseltamivir 75 mg by mouth every 12 hours. She was transferred to a medical floor, where she completed a five-day course of oseltamivir.

As a result of timely intervention, the patient was discharged in stable condition on a therapeutic regimen that included albuterol, fluticasone, and salmeterol inhalation, in addition to tapered-dose steroids. She was advised to follow up with her primary care provider and at the pulmonary clinic.

CONCLUSION
To our knowledge, this is the first reported case of acute pericarditis in a patient with concomitant acute infections with influenza A and B. According to conclusions reached in recent literature, further research is needed to explain the pathophysiology of influenza viral infections, associated cardiovascular morbidity and mortality, and the degree to which these can be prevented by influenza vaccination.^1,28 Also to be pursued through research is a better understanding of the morbidity and mortality associated with influenza viruses, especially in children and in adults affected by asthma, cardiac disease, and/or obesity.

REFERENCES
1. Finelli L, Chaves SS. Influenza and acute myocardial infarction. J Infect Dis. 2011;203(12):

1701-1704.

2. Steiger HV, Rimbach K, Müller E, Breitkreutz R. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Eur J Emerg Med. 2009;16(2): 103-105.

3. Goodman A, Perera P, Mailhot T, Mandavia D. The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade.

J Emerg Trauma Shock. 2012;5(1):72-75.

4. Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007;27(6):1595-1610.

5. Papanagnou D, Stone MB. Massive right atrial thrombus masquerading as cardiac tamponade. Acad Emerg Med. 2010;17(2):E11.

6. Saito Y, Donohue A, Attai S, et al. The syndrome of cardiac tamponade with “small” pericardial effusion. Echocardiography. 2008;25(3): 321-327.

7. Lin E, Boire A, Hemmige V, et al. Cardiac tamponade mimicking tuberculous pericarditis as the initial presentation of chronic lymphocytic leukemia in a 58-year-old woman: a case report. J Med Case Rep. 2010;4:246.

8. Meniconi A, Attenhofer Jost CH, Jenni R. How to survive myocardial rupture after myocardial infarction. Heart. 2000;84(5):552.

9. Kosuge M, Kimura K, Ishikawa T, et al. Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circ J. 2006;70(3):222-226.

10. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36(3):959-969.

11. Goldhaber SZ. Deep venous thrombosis and pulmonary thromboembolism. In: Fauci AS, Braunwald E, Kasper DL, et al. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill Medical; 2008:1651–1657.

12. Brooks EG, Trotman W, Wadsworth MP, et al. Valves of the deep venous system: an overlooked risk factor. Blood. 2009;114(6):1276-1279.

13. Kyrle PA, Eichinger S. Is Virchow’s triad complete? Blood. 2009;114(6):1138-1139.

14. CDC. Seasonal influenza (flu): types of influenza viruses (2012). www.cdc.gov/flu/about/viruses/types.htm. Accessed October 24, 2012.

15. CDC. Seasonal influenza (flu)(2012). www.cdc .gov/flu. Accessed October 24, 2012.

16. Eccles R. Understanding the symptoms of the common cold and influenza. Lancet Infect Dis. 2005;5(11):718-725.

17. Angelo SJ, Marshall PS, Chrissoheris MP, Chaves AM. Clinical characteristics associated with poor outcome in patients acutely infected with Influenza A. Conn Med. 2004;68(4):199-205.

18. Murin S, Bilello K. Respiratory tract infections: another reason not to smoke. Cleve Clin J Med. 2005;72(10):916-920.

19. Ray CG, Icenogle TB, Minnich LL, et al. The use of intravenous ribavirin to treat influenza virus–associated acute myocarditis. J Infect Dis. 1989; 159(5):829-836.

20. Fairley CK, Ryan M, Wall PG, Weinberg J. The organism reported to cause infective myocarditis and pericarditis in England and Wales. J Infect. 1996;32(3):223-225.

21. Proby CM, Hackett D, Gupta S, Cox TM. Acute myopericarditis in influenza A infection. Q J Med. 1986;60(233):887-892.

22. Streifler JJ, Dux S, Garty M, Rosenfeld JB. Recurrent pericarditis: a rare complication of influenza vaccination. Br Med J (Clin Res Ed). 1981; 283(6290):526-527.

23. Desson JF, Leprévost M, Vabret F, Davy A. Acute benign pericarditis after anti-influenza vaccination [in French]. Presse Med. 1997;26 (9):415.

24. BinaxNOW® Influenza A&B Test Kit (product instructions). www.diagnosticsdirect2u.com/images/PDF/Binax%20Now%20416-022%20PPI .pdf. Accessed October 24, 2012.

25. 510(k) Substantial Equivalence Determination Decision Summary [BinaxNow® Influenza A & B Test] (2009). www.accessdata.fda.gov/cdrh_docs/reviews/K062109.pdf. Accessed October 24, 2012.

26. Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation. 2010;121(7):916-928.

27. Maisch B, Seferovic PM, Ristic AD, et al; Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases: executive summary. Eur Heart J. 2004;25(7):587-610.

28. McCullers JA, Hayden FG. Fatal influenza B infections: time to reexamine influenza research priorities. J Infect Dis. 2012;205(6):870-872.

CASE: Behavioral changes

Mr. K, age 45, is brought to the emergency department (ED) by his wife for severe paranoia, combative behavior, confusion, and slowed cognition. Mr. K tells the ED staff that a chemical abrasion he sustained a few weeks earlier has spread to his penis, and insists that his penis is retracting into his body. He has tied a string around his penis to keep it from disappearing into his body. According to Mr. K’s wife, he went to an urgent care clinic 2 weeks ago after he sustained chemical abrasions from exposure to cleaning solution at home. The provider at the urgent care clinic started Mr. K on an unknown dose of oral prednisone.

Mr. K’s wife reports that her husband had a dysphoric episode approximately 6 months ago when his business was struggling but his mood improved without psychiatric care. Mr. K’s medical history includes episodic sarcoidosis of the eyes, skin, and lungs. In the past these symptoms remitted after he received oral prednisone.

ED clinicians consider neurosarcoidosis and substance-induced delirium in the differential diagnosis (Table).¹ A CT scan of the head fails to show lesions suggestive of neurosarcoidosis. Chest radiography does not reveal lesions suggestive of lung sarcoids and Mr. K has no skin lesions.

Table

DSM-IV-TR criteria for substance-induced delirium

Mr. K is admitted to the psychiatric inpatient unit for acute stabilization, where he remains aggressive and combative. He throws chairs at his peers and staff on the unit and is placed in physical restraints. He requires several doses of IM haloperidol, 5 mg, lorazepam, 2 mg, and diphenhydramine, 50 mg, for severe agitation. Mr. K is guarded, perseverative, and selectively mute. He avoids eye contact and has poor grooming. He has slow thought processing and displays concrete thought process. Prednisone is discontinued and olanzapine, titrated to 30 mg/d, and mirtazapine, titrated to 30 mg/d, are started for psychosis and depression.

Mr. K’s mood and behavior eventually return to baseline but slowed cognition persists. He is discharged from our facility.

The authors’ observations

Cortisone was first used to treat rheumatoid arthritis in 1948 and corticosteroids have been linked to multiple neuropsychiatric complications that have been broadly defined as steroid psychosis. This syndrome includes reversible behavioral manifestations such as hypomania, irritability, mood reactivity, anxiety, and insomnia in addition to more severe symptoms such as depression, mania, and psychosis.² Although mild cognitive deficits have been noted in patients taking corticosteroids, most published cases have focused on steroid-induced psychosis.

In 1984, Varney et al³ noted a phenomenon they called “steroid dementia” in 6 patients treated with corticosteroids. On first evaluation, these patients presented with symptoms similar to early Alzheimer’s dementia—impaired memory, attention, and concentration. Three patients initially were diagnosed first with Alzheimer’s dementia until their symptoms spontaneously improved when steroids were reduced or discontinued. Although their presentation resembled Alzheimer’s dementia, patients with steroid dementia had a specific cognitive presentation associated with corticosteroid use. Symptoms included impaired verbal memory and spatial thinking but normal procedural memory. These patients showed intact immediate recall but impaired delayed recall with difficulty tracking conversations and word finding. Overall, patients with steroid dementia showed a predominance of verbal declarative memory deficits out of proportion to other cognitive symptoms. These symptoms and recent corticosteroid exposure differentiated steroid dementia from other forms of dementia.

In a later article, Varney reviewed electroencephalography (EEG) and CT findings associated with steroid dementia, noting bilateral EEG abnormalities and acute cortical atrophy on CT.⁴ Steroid dementia largely was reversible, resolving 3 to 11 months after corticosteroid discontinuation. Additionally, Varney noted that patients who had psychosis and dementia had more severe and longer-lasting dementia.

TREATMENT: Progressive decline

Mr. K is college educated, has been married for 15 years, has 2 children, age 9 and 11, and owns a successful basketball coaching business. He has no history of substance abuse, legal issues, or violence. He reports a good childhood with normal developmental milestones and no history of trauma.

In the 6 months after his initial psychiatric admission, Mr. K sees various outpatient providers, who change his psychotropics multiple times. He also receives 4 courses of prednisone for ocular sarcoidosis. He is admitted twice to other psychiatric facilities. After he has paranoid interactions with colleagues and families of the youth he coaches, his business fails.

After his third psychiatric inpatient hospitalization, Mr. K becomes severely paranoid, believing his wife is having an affair. He becomes physically abusive to his wife, who obtains a restraining order and leaves with their children. Mr. K barely leaves his house and stops grooming. A friend notes that Mr. K’s home has become uninhabitable, and it goes into foreclosure. After Mr. K’s neighbors report combative behavior and paranoia, police bring him in on an involuntary hold for a fourth psychiatric hospitalization (the second in our facility).

During this hospitalization—6 months after the initial ED presentation—the neurology team conducts a repeat medical workup. EEG shows generalized slowing. Head CT and MRI show diffuse cortical atrophy that was not seen in previous imaging. Mr. K has ocular lesions characteristic of ocular sarcoidosis. His mental status examination is similar to his first presentation except that the psychosis and thought disorganization are considerably worse. His cognitive functioning also shows significant decline. Cognitive screening reveals intact remote memory with impaired recent memory. His thinking is concrete and his verbal memory is markedly impaired. His Mini-Mental State Examination score is 27/30, indicating functional capacity that is better than his clinical presentation. Because of difficulty with concentration and verbal processing, Mr. K is unable to complete the Minnesota Multiphasic Personality Inventory despite substantial assistance. On most days he cannot recall recent conversations with his wife, staff, or physicians. He is taking no medications at this time.

Mr. K is restarted on olanzapine, titrated to 30 mg/d, to control his psychosis; this medication was effective during his last stay in our facility. Oral prednisone is discontinued and methotrexate, 10 mg/week, is initiated for ocular sarcoidosis. Based on recommendations from a case series report,⁵ we start Mr. K on lithium, titrated to 600 mg twice a day, for steroid-induced mood symptoms, Mr. K’s psychosis and mood improve dramatically once he reaches a therapeutic lithium level; however, his cognition remains slowed and he is unable to care for his basic needs.

The authors’ observations

Steroid dementia may be the result of effects in the medial temporal lobe, specifically dorsolateral prefrontal cortex, which impairs working memory, and the parahippocampal gyrus.^6,7 The cognitive presentation of steroid dementia Varney et al³ described has been replicated in healthy volunteers who received corticosteroids.³ Patients with Cushing’s syndrome also have been noted to have diminished hippocampal volume and similar cognitive deficits. Cognitive impairment experienced by patients treated with corticosteroids may be caused by neuronal death in the hippocampus and dorsolateral prefrontal cortex. The etiology of cell death is multifactorial and includes glutamate-mediated excitotoxicity, activation of proinflammatory pathways, inhibited utilization of glucose in the hippocampus, telomere shortening, and diminished cell repair by brain-derived neurotrophic factor. The net result is significant, widespread damage that in some cases is irreversible.⁸

Because of the severity of Mr. K’s psychosis and personality change from baseline, his cognitive symptoms were largely overlooked during his first psychiatric hospitalization. The affective flattening, delayed verbal response, and markedly concrete thought process were considered within the spectrum of resolving psychosis. After further hospitalizations and abnormal results on cognitive testing, Mr. K’s cognitive impairment was fully noted. His symptoms match those of previously documented cases of steroid dementia, including verbal deficits out of proportion to other impairment, acute cerebral atrophy on CT after corticosteroid treatment, and gradual improvement of symptoms when corticosteroids were discontinued.

Management recommendations

Educate patients taking steroids about possible side effects of mood changes, psychosis, and cognitive deficits. Close monitoring of patients on corticosteroids is paramount. If psychiatric or cognitive symptoms develop, gradually discontinue the corticosteroid and seek other treatments.

Randomized, placebo-controlled trials of lamotrigine and memantine have shown these medications are cognitively protective for patients taking prednisone.⁹

OUTCOME: Long-term deficits

After a 33-day stay in our adult inpatient psychiatric facility, the county places Mr. K in a permanent conservatorship for severe grave disability. He is discharged to a long-term psychiatric care locked facility for ongoing management. Mr. K spends 20 months in the long-term care facility while his family remains hopeful for his recovery and return home. He is admitted to our facility for acute stabilization of psychotic symptoms after he is released from the locked facility. Although no imaging studies are conducted, he remains significantly forgetful. Additionally, his paranoia persists.

Mr. K is poorly compliant with his psychotropics, which include divalproex, 1,000 mg/d, and olanzapine, 30 mg/d. Although he is discharged home with his family, his functional capacity is less than expected and he requires continuous support. Insisting that Mr. K abstain from steroids after the first psychiatric hospitalization might have prevented this seemingly irreversible dementia.

Related Resources

• Sacks O, Shulman M. Steroid dementia: an overlooked diagnosis? Neurology. 2005;64(4):707-709.
• Cipriani G, Picchi L, Vedovello M, et al. Reversible dementia from corticosteroid therapy. Clinical Geriatrics. 2012;20(7):38-41.

Drug Brand Names

• Diphenhydramine • Benadryl
• Divalproex • Depakote
• Haloperidol • Haldol
• Lamotrigine • Lamictal
• Lithium • Eskalith, Lithobid
• Lorazepam • Ativan
• Memantine • Namenda
• Methotrexate • Rheumatrex, Trexall
• Mirtazapine • Remeron
• Olanzapine • Zyprexa
• Prednisone • Deltasone, Meticorten, others

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Behavioral changes

Mr. K, age 45, is brought to the emergency department (ED) by his wife for severe paranoia, combative behavior, confusion, and slowed cognition. Mr. K tells the ED staff that a chemical abrasion he sustained a few weeks earlier has spread to his penis, and insists that his penis is retracting into his body. He has tied a string around his penis to keep it from disappearing into his body. According to Mr. K’s wife, he went to an urgent care clinic 2 weeks ago after he sustained chemical abrasions from exposure to cleaning solution at home. The provider at the urgent care clinic started Mr. K on an unknown dose of oral prednisone.

Mr. K’s wife reports that her husband had a dysphoric episode approximately 6 months ago when his business was struggling but his mood improved without psychiatric care. Mr. K’s medical history includes episodic sarcoidosis of the eyes, skin, and lungs. In the past these symptoms remitted after he received oral prednisone.

ED clinicians consider neurosarcoidosis and substance-induced delirium in the differential diagnosis (Table).¹ A CT scan of the head fails to show lesions suggestive of neurosarcoidosis. Chest radiography does not reveal lesions suggestive of lung sarcoids and Mr. K has no skin lesions.

Table

DSM-IV-TR criteria for substance-induced delirium

Mr. K is admitted to the psychiatric inpatient unit for acute stabilization, where he remains aggressive and combative. He throws chairs at his peers and staff on the unit and is placed in physical restraints. He requires several doses of IM haloperidol, 5 mg, lorazepam, 2 mg, and diphenhydramine, 50 mg, for severe agitation. Mr. K is guarded, perseverative, and selectively mute. He avoids eye contact and has poor grooming. He has slow thought processing and displays concrete thought process. Prednisone is discontinued and olanzapine, titrated to 30 mg/d, and mirtazapine, titrated to 30 mg/d, are started for psychosis and depression.

Mr. K’s mood and behavior eventually return to baseline but slowed cognition persists. He is discharged from our facility.

The authors’ observations

Cortisone was first used to treat rheumatoid arthritis in 1948 and corticosteroids have been linked to multiple neuropsychiatric complications that have been broadly defined as steroid psychosis. This syndrome includes reversible behavioral manifestations such as hypomania, irritability, mood reactivity, anxiety, and insomnia in addition to more severe symptoms such as depression, mania, and psychosis.² Although mild cognitive deficits have been noted in patients taking corticosteroids, most published cases have focused on steroid-induced psychosis.

In 1984, Varney et al³ noted a phenomenon they called “steroid dementia” in 6 patients treated with corticosteroids. On first evaluation, these patients presented with symptoms similar to early Alzheimer’s dementia—impaired memory, attention, and concentration. Three patients initially were diagnosed first with Alzheimer’s dementia until their symptoms spontaneously improved when steroids were reduced or discontinued. Although their presentation resembled Alzheimer’s dementia, patients with steroid dementia had a specific cognitive presentation associated with corticosteroid use. Symptoms included impaired verbal memory and spatial thinking but normal procedural memory. These patients showed intact immediate recall but impaired delayed recall with difficulty tracking conversations and word finding. Overall, patients with steroid dementia showed a predominance of verbal declarative memory deficits out of proportion to other cognitive symptoms. These symptoms and recent corticosteroid exposure differentiated steroid dementia from other forms of dementia.

In a later article, Varney reviewed electroencephalography (EEG) and CT findings associated with steroid dementia, noting bilateral EEG abnormalities and acute cortical atrophy on CT.⁴ Steroid dementia largely was reversible, resolving 3 to 11 months after corticosteroid discontinuation. Additionally, Varney noted that patients who had psychosis and dementia had more severe and longer-lasting dementia.

TREATMENT: Progressive decline

Mr. K is college educated, has been married for 15 years, has 2 children, age 9 and 11, and owns a successful basketball coaching business. He has no history of substance abuse, legal issues, or violence. He reports a good childhood with normal developmental milestones and no history of trauma.

In the 6 months after his initial psychiatric admission, Mr. K sees various outpatient providers, who change his psychotropics multiple times. He also receives 4 courses of prednisone for ocular sarcoidosis. He is admitted twice to other psychiatric facilities. After he has paranoid interactions with colleagues and families of the youth he coaches, his business fails.

After his third psychiatric inpatient hospitalization, Mr. K becomes severely paranoid, believing his wife is having an affair. He becomes physically abusive to his wife, who obtains a restraining order and leaves with their children. Mr. K barely leaves his house and stops grooming. A friend notes that Mr. K’s home has become uninhabitable, and it goes into foreclosure. After Mr. K’s neighbors report combative behavior and paranoia, police bring him in on an involuntary hold for a fourth psychiatric hospitalization (the second in our facility).

During this hospitalization—6 months after the initial ED presentation—the neurology team conducts a repeat medical workup. EEG shows generalized slowing. Head CT and MRI show diffuse cortical atrophy that was not seen in previous imaging. Mr. K has ocular lesions characteristic of ocular sarcoidosis. His mental status examination is similar to his first presentation except that the psychosis and thought disorganization are considerably worse. His cognitive functioning also shows significant decline. Cognitive screening reveals intact remote memory with impaired recent memory. His thinking is concrete and his verbal memory is markedly impaired. His Mini-Mental State Examination score is 27/30, indicating functional capacity that is better than his clinical presentation. Because of difficulty with concentration and verbal processing, Mr. K is unable to complete the Minnesota Multiphasic Personality Inventory despite substantial assistance. On most days he cannot recall recent conversations with his wife, staff, or physicians. He is taking no medications at this time.

Mr. K is restarted on olanzapine, titrated to 30 mg/d, to control his psychosis; this medication was effective during his last stay in our facility. Oral prednisone is discontinued and methotrexate, 10 mg/week, is initiated for ocular sarcoidosis. Based on recommendations from a case series report,⁵ we start Mr. K on lithium, titrated to 600 mg twice a day, for steroid-induced mood symptoms, Mr. K’s psychosis and mood improve dramatically once he reaches a therapeutic lithium level; however, his cognition remains slowed and he is unable to care for his basic needs.

The authors’ observations

Steroid dementia may be the result of effects in the medial temporal lobe, specifically dorsolateral prefrontal cortex, which impairs working memory, and the parahippocampal gyrus.^6,7 The cognitive presentation of steroid dementia Varney et al³ described has been replicated in healthy volunteers who received corticosteroids.³ Patients with Cushing’s syndrome also have been noted to have diminished hippocampal volume and similar cognitive deficits. Cognitive impairment experienced by patients treated with corticosteroids may be caused by neuronal death in the hippocampus and dorsolateral prefrontal cortex. The etiology of cell death is multifactorial and includes glutamate-mediated excitotoxicity, activation of proinflammatory pathways, inhibited utilization of glucose in the hippocampus, telomere shortening, and diminished cell repair by brain-derived neurotrophic factor. The net result is significant, widespread damage that in some cases is irreversible.⁸

Because of the severity of Mr. K’s psychosis and personality change from baseline, his cognitive symptoms were largely overlooked during his first psychiatric hospitalization. The affective flattening, delayed verbal response, and markedly concrete thought process were considered within the spectrum of resolving psychosis. After further hospitalizations and abnormal results on cognitive testing, Mr. K’s cognitive impairment was fully noted. His symptoms match those of previously documented cases of steroid dementia, including verbal deficits out of proportion to other impairment, acute cerebral atrophy on CT after corticosteroid treatment, and gradual improvement of symptoms when corticosteroids were discontinued.

Management recommendations

Educate patients taking steroids about possible side effects of mood changes, psychosis, and cognitive deficits. Close monitoring of patients on corticosteroids is paramount. If psychiatric or cognitive symptoms develop, gradually discontinue the corticosteroid and seek other treatments.

Randomized, placebo-controlled trials of lamotrigine and memantine have shown these medications are cognitively protective for patients taking prednisone.⁹

OUTCOME: Long-term deficits

After a 33-day stay in our adult inpatient psychiatric facility, the county places Mr. K in a permanent conservatorship for severe grave disability. He is discharged to a long-term psychiatric care locked facility for ongoing management. Mr. K spends 20 months in the long-term care facility while his family remains hopeful for his recovery and return home. He is admitted to our facility for acute stabilization of psychotic symptoms after he is released from the locked facility. Although no imaging studies are conducted, he remains significantly forgetful. Additionally, his paranoia persists.

Mr. K is poorly compliant with his psychotropics, which include divalproex, 1,000 mg/d, and olanzapine, 30 mg/d. Although he is discharged home with his family, his functional capacity is less than expected and he requires continuous support. Insisting that Mr. K abstain from steroids after the first psychiatric hospitalization might have prevented this seemingly irreversible dementia.

Related Resources

• Sacks O, Shulman M. Steroid dementia: an overlooked diagnosis? Neurology. 2005;64(4):707-709.
• Cipriani G, Picchi L, Vedovello M, et al. Reversible dementia from corticosteroid therapy. Clinical Geriatrics. 2012;20(7):38-41.

Drug Brand Names

• Diphenhydramine • Benadryl
• Divalproex • Depakote
• Haloperidol • Haldol
• Lamotrigine • Lamictal
• Lithium • Eskalith, Lithobid
• Lorazepam • Ativan
• Memantine • Namenda
• Methotrexate • Rheumatrex, Trexall
• Mirtazapine • Remeron
• Olanzapine • Zyprexa
• Prednisone • Deltasone, Meticorten, others

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Behavioral changes

Mr. K, age 45, is brought to the emergency department (ED) by his wife for severe paranoia, combative behavior, confusion, and slowed cognition. Mr. K tells the ED staff that a chemical abrasion he sustained a few weeks earlier has spread to his penis, and insists that his penis is retracting into his body. He has tied a string around his penis to keep it from disappearing into his body. According to Mr. K’s wife, he went to an urgent care clinic 2 weeks ago after he sustained chemical abrasions from exposure to cleaning solution at home. The provider at the urgent care clinic started Mr. K on an unknown dose of oral prednisone.

Mr. K’s wife reports that her husband had a dysphoric episode approximately 6 months ago when his business was struggling but his mood improved without psychiatric care. Mr. K’s medical history includes episodic sarcoidosis of the eyes, skin, and lungs. In the past these symptoms remitted after he received oral prednisone.

ED clinicians consider neurosarcoidosis and substance-induced delirium in the differential diagnosis (Table).¹ A CT scan of the head fails to show lesions suggestive of neurosarcoidosis. Chest radiography does not reveal lesions suggestive of lung sarcoids and Mr. K has no skin lesions.

Table

DSM-IV-TR criteria for substance-induced delirium

Mr. K is admitted to the psychiatric inpatient unit for acute stabilization, where he remains aggressive and combative. He throws chairs at his peers and staff on the unit and is placed in physical restraints. He requires several doses of IM haloperidol, 5 mg, lorazepam, 2 mg, and diphenhydramine, 50 mg, for severe agitation. Mr. K is guarded, perseverative, and selectively mute. He avoids eye contact and has poor grooming. He has slow thought processing and displays concrete thought process. Prednisone is discontinued and olanzapine, titrated to 30 mg/d, and mirtazapine, titrated to 30 mg/d, are started for psychosis and depression.

Mr. K’s mood and behavior eventually return to baseline but slowed cognition persists. He is discharged from our facility.

The authors’ observations

Cortisone was first used to treat rheumatoid arthritis in 1948 and corticosteroids have been linked to multiple neuropsychiatric complications that have been broadly defined as steroid psychosis. This syndrome includes reversible behavioral manifestations such as hypomania, irritability, mood reactivity, anxiety, and insomnia in addition to more severe symptoms such as depression, mania, and psychosis.² Although mild cognitive deficits have been noted in patients taking corticosteroids, most published cases have focused on steroid-induced psychosis.

In 1984, Varney et al³ noted a phenomenon they called “steroid dementia” in 6 patients treated with corticosteroids. On first evaluation, these patients presented with symptoms similar to early Alzheimer’s dementia—impaired memory, attention, and concentration. Three patients initially were diagnosed first with Alzheimer’s dementia until their symptoms spontaneously improved when steroids were reduced or discontinued. Although their presentation resembled Alzheimer’s dementia, patients with steroid dementia had a specific cognitive presentation associated with corticosteroid use. Symptoms included impaired verbal memory and spatial thinking but normal procedural memory. These patients showed intact immediate recall but impaired delayed recall with difficulty tracking conversations and word finding. Overall, patients with steroid dementia showed a predominance of verbal declarative memory deficits out of proportion to other cognitive symptoms. These symptoms and recent corticosteroid exposure differentiated steroid dementia from other forms of dementia.

In a later article, Varney reviewed electroencephalography (EEG) and CT findings associated with steroid dementia, noting bilateral EEG abnormalities and acute cortical atrophy on CT.⁴ Steroid dementia largely was reversible, resolving 3 to 11 months after corticosteroid discontinuation. Additionally, Varney noted that patients who had psychosis and dementia had more severe and longer-lasting dementia.

TREATMENT: Progressive decline

Mr. K is college educated, has been married for 15 years, has 2 children, age 9 and 11, and owns a successful basketball coaching business. He has no history of substance abuse, legal issues, or violence. He reports a good childhood with normal developmental milestones and no history of trauma.

In the 6 months after his initial psychiatric admission, Mr. K sees various outpatient providers, who change his psychotropics multiple times. He also receives 4 courses of prednisone for ocular sarcoidosis. He is admitted twice to other psychiatric facilities. After he has paranoid interactions with colleagues and families of the youth he coaches, his business fails.

After his third psychiatric inpatient hospitalization, Mr. K becomes severely paranoid, believing his wife is having an affair. He becomes physically abusive to his wife, who obtains a restraining order and leaves with their children. Mr. K barely leaves his house and stops grooming. A friend notes that Mr. K’s home has become uninhabitable, and it goes into foreclosure. After Mr. K’s neighbors report combative behavior and paranoia, police bring him in on an involuntary hold for a fourth psychiatric hospitalization (the second in our facility).

During this hospitalization—6 months after the initial ED presentation—the neurology team conducts a repeat medical workup. EEG shows generalized slowing. Head CT and MRI show diffuse cortical atrophy that was not seen in previous imaging. Mr. K has ocular lesions characteristic of ocular sarcoidosis. His mental status examination is similar to his first presentation except that the psychosis and thought disorganization are considerably worse. His cognitive functioning also shows significant decline. Cognitive screening reveals intact remote memory with impaired recent memory. His thinking is concrete and his verbal memory is markedly impaired. His Mini-Mental State Examination score is 27/30, indicating functional capacity that is better than his clinical presentation. Because of difficulty with concentration and verbal processing, Mr. K is unable to complete the Minnesota Multiphasic Personality Inventory despite substantial assistance. On most days he cannot recall recent conversations with his wife, staff, or physicians. He is taking no medications at this time.

Mr. K is restarted on olanzapine, titrated to 30 mg/d, to control his psychosis; this medication was effective during his last stay in our facility. Oral prednisone is discontinued and methotrexate, 10 mg/week, is initiated for ocular sarcoidosis. Based on recommendations from a case series report,⁵ we start Mr. K on lithium, titrated to 600 mg twice a day, for steroid-induced mood symptoms, Mr. K’s psychosis and mood improve dramatically once he reaches a therapeutic lithium level; however, his cognition remains slowed and he is unable to care for his basic needs.

The authors’ observations

Steroid dementia may be the result of effects in the medial temporal lobe, specifically dorsolateral prefrontal cortex, which impairs working memory, and the parahippocampal gyrus.^6,7 The cognitive presentation of steroid dementia Varney et al³ described has been replicated in healthy volunteers who received corticosteroids.³ Patients with Cushing’s syndrome also have been noted to have diminished hippocampal volume and similar cognitive deficits. Cognitive impairment experienced by patients treated with corticosteroids may be caused by neuronal death in the hippocampus and dorsolateral prefrontal cortex. The etiology of cell death is multifactorial and includes glutamate-mediated excitotoxicity, activation of proinflammatory pathways, inhibited utilization of glucose in the hippocampus, telomere shortening, and diminished cell repair by brain-derived neurotrophic factor. The net result is significant, widespread damage that in some cases is irreversible.⁸

Because of the severity of Mr. K’s psychosis and personality change from baseline, his cognitive symptoms were largely overlooked during his first psychiatric hospitalization. The affective flattening, delayed verbal response, and markedly concrete thought process were considered within the spectrum of resolving psychosis. After further hospitalizations and abnormal results on cognitive testing, Mr. K’s cognitive impairment was fully noted. His symptoms match those of previously documented cases of steroid dementia, including verbal deficits out of proportion to other impairment, acute cerebral atrophy on CT after corticosteroid treatment, and gradual improvement of symptoms when corticosteroids were discontinued.

Management recommendations

Educate patients taking steroids about possible side effects of mood changes, psychosis, and cognitive deficits. Close monitoring of patients on corticosteroids is paramount. If psychiatric or cognitive symptoms develop, gradually discontinue the corticosteroid and seek other treatments.

Randomized, placebo-controlled trials of lamotrigine and memantine have shown these medications are cognitively protective for patients taking prednisone.⁹

OUTCOME: Long-term deficits

After a 33-day stay in our adult inpatient psychiatric facility, the county places Mr. K in a permanent conservatorship for severe grave disability. He is discharged to a long-term psychiatric care locked facility for ongoing management. Mr. K spends 20 months in the long-term care facility while his family remains hopeful for his recovery and return home. He is admitted to our facility for acute stabilization of psychotic symptoms after he is released from the locked facility. Although no imaging studies are conducted, he remains significantly forgetful. Additionally, his paranoia persists.

Mr. K is poorly compliant with his psychotropics, which include divalproex, 1,000 mg/d, and olanzapine, 30 mg/d. Although he is discharged home with his family, his functional capacity is less than expected and he requires continuous support. Insisting that Mr. K abstain from steroids after the first psychiatric hospitalization might have prevented this seemingly irreversible dementia.

Related Resources

• Sacks O, Shulman M. Steroid dementia: an overlooked diagnosis? Neurology. 2005;64(4):707-709.
• Cipriani G, Picchi L, Vedovello M, et al. Reversible dementia from corticosteroid therapy. Clinical Geriatrics. 2012;20(7):38-41.

Drug Brand Names

• Diphenhydramine • Benadryl
• Divalproex • Depakote
• Haloperidol • Haldol
• Lamotrigine • Lamictal
• Lithium • Eskalith, Lithobid
• Lorazepam • Ativan
• Memantine • Namenda
• Methotrexate • Rheumatrex, Trexall
• Mirtazapine • Remeron
• Olanzapine • Zyprexa
• Prednisone • Deltasone, Meticorten, others

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

A 63-YEAR-OLD MAN came to our clinic complaining of a rash on his penis. He indicated that the rash had been there for almost 2 years and that he’d seen 2 other doctors about it, but they’d been unable to make a diagnosis.

The patient said the rash was mildly painful and tender. He denied pain on urination, discharge, fever, malaise, or arthralgias. He also denied any sexual contact outside of his marriage and indicated that he had not been able to have intimate contact with his wife because of the problem.

The patient was uncircumcised and when the foreskin was retracted, a bright red erythematous nonscaly circumferential plaque was visible on the glans penis, spreading to the foreskin (FIGURE 1).

FIGURE 1
A nonscaly, circumferential plaque on the glans penis

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Zoon’s balanitis

We ordered a biopsy because we suspected that the cause of the rash was either erythroplasia of Queyrat (a premalignant condition also known as Bowen’s disease of the glans penis) or Zoon’s balanitis (plasma cell balanitis or balanitis circumscripta plasmacellularis). The biopsy report confirmed the diagnosis of Zoon’s balanitis and showed no signs of malignancy. The features of Zoon’s balanitis include epidermal atrophy, loss of rete ridges, spongiosis, and subepidermal plasma cell infiltrate without evidence of malignancy (FIGURE 2).

FIGURE 2
Dense plasmacytic infiltration underlying the mucosal epidermis

Condition affects older, uncircumcised men
Zoon’s balanitis is thought to be a benign condition that typically affects uncircumcised middle-aged to elderly men.^1,2 Worldwide prevalence among uncircumcised men is approximately 3%.² The etiology is unknown; it’s thought that this condition may be caused by friction, trauma, heat, lack of hygiene, exogenous or infectious agents, an IgE hypersensitivity, or a chronic infection with Mycobacterium smegmatis.^1,2

Typically, the appearance of the lesion precedes diagnosis by about one to 2 years.¹ The patient usually complains of mild pruritus and tenderness. Undergarments may be bloodstained.

The differential for penile lesions is extensive, and includes psoriasis, nummular eczema, candidiasis, herpes simplex, scabies, lichen sclerosus et atrophicus or lichen planus, syphilis, balanitis, and erythroplasia of Queyrat.

The lesion associated with Zoon’s balanitis is a solitary, glistening, shiny, red-to-orange plaque of the glans penis or prepuce of an uncircumcised male. Pinpoint erythematous spots or “cayenne pepper spots” may also be associated with this condition.

Patients with erythroplasia of Queyrat have either a solitary or multiple nonhealing erythematous plaques on the glans penis. These lesions may also affect the adjacent mucosal epithelium. As is true with Zoon’s balanitis, the typical patient is uncircumcised and middle-aged to elderly.^1,2

Presentations may be similar, but treatment differs

Because the treatments for Zoon’s balanitis and erythroplasia of Queyrat are different, a biopsy is imperative. Erythroplasia of Queyrat is a premalignant condition that is treated with topical fluorouracil or surgical excision.³ Treatment for Zoon’s balanitis consists of a topical corticosteroid with or without topical anticandidal agents and circumcision after the acute inflammation resolves.^1,2 (If a skin biopsy cannot be obtained in the clinic, the foreskin [if affected] can be sent for biopsy after the circumcision.)

If resolution is not seen with topical steroid treatment, other treatments have demonstrated efficacy. These include topical tacrolimus, as well as YAG and carbon dioxide laser treatments.^4-6

Although information is limited on rates of recurrence, circumcision is considered the treatment of choice and is usually curative.¹

Ointment does the trick for our patient

Our patient was treated with a single combined topical ointment consisting of nystatin and triamcinolone cream with zinc oxide. The lesion resolved completely after 10 days. We requested a urology consult so that a circumcision could be performed.

CORRESPONDENCE Matthew R. Noss, DO, MSEd, Fort Belvoir Community Hospital Family Medicine Clinic, 1st Floor, Eagle Pavilion, 9300 Dewitt Loop, Ft. Belvoir, VA 22060; [email protected]

A 63-YEAR-OLD MAN came to our clinic complaining of a rash on his penis. He indicated that the rash had been there for almost 2 years and that he’d seen 2 other doctors about it, but they’d been unable to make a diagnosis.

The patient said the rash was mildly painful and tender. He denied pain on urination, discharge, fever, malaise, or arthralgias. He also denied any sexual contact outside of his marriage and indicated that he had not been able to have intimate contact with his wife because of the problem.

The patient was uncircumcised and when the foreskin was retracted, a bright red erythematous nonscaly circumferential plaque was visible on the glans penis, spreading to the foreskin (FIGURE 1).

FIGURE 1
A nonscaly, circumferential plaque on the glans penis

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Zoon’s balanitis

We ordered a biopsy because we suspected that the cause of the rash was either erythroplasia of Queyrat (a premalignant condition also known as Bowen’s disease of the glans penis) or Zoon’s balanitis (plasma cell balanitis or balanitis circumscripta plasmacellularis). The biopsy report confirmed the diagnosis of Zoon’s balanitis and showed no signs of malignancy. The features of Zoon’s balanitis include epidermal atrophy, loss of rete ridges, spongiosis, and subepidermal plasma cell infiltrate without evidence of malignancy (FIGURE 2).

FIGURE 2
Dense plasmacytic infiltration underlying the mucosal epidermis

Condition affects older, uncircumcised men
Zoon’s balanitis is thought to be a benign condition that typically affects uncircumcised middle-aged to elderly men.^1,2 Worldwide prevalence among uncircumcised men is approximately 3%.² The etiology is unknown; it’s thought that this condition may be caused by friction, trauma, heat, lack of hygiene, exogenous or infectious agents, an IgE hypersensitivity, or a chronic infection with Mycobacterium smegmatis.^1,2

Typically, the appearance of the lesion precedes diagnosis by about one to 2 years.¹ The patient usually complains of mild pruritus and tenderness. Undergarments may be bloodstained.

The differential for penile lesions is extensive, and includes psoriasis, nummular eczema, candidiasis, herpes simplex, scabies, lichen sclerosus et atrophicus or lichen planus, syphilis, balanitis, and erythroplasia of Queyrat.

The lesion associated with Zoon’s balanitis is a solitary, glistening, shiny, red-to-orange plaque of the glans penis or prepuce of an uncircumcised male. Pinpoint erythematous spots or “cayenne pepper spots” may also be associated with this condition.

Patients with erythroplasia of Queyrat have either a solitary or multiple nonhealing erythematous plaques on the glans penis. These lesions may also affect the adjacent mucosal epithelium. As is true with Zoon’s balanitis, the typical patient is uncircumcised and middle-aged to elderly.^1,2

Presentations may be similar, but treatment differs

Because the treatments for Zoon’s balanitis and erythroplasia of Queyrat are different, a biopsy is imperative. Erythroplasia of Queyrat is a premalignant condition that is treated with topical fluorouracil or surgical excision.³ Treatment for Zoon’s balanitis consists of a topical corticosteroid with or without topical anticandidal agents and circumcision after the acute inflammation resolves.^1,2 (If a skin biopsy cannot be obtained in the clinic, the foreskin [if affected] can be sent for biopsy after the circumcision.)

If resolution is not seen with topical steroid treatment, other treatments have demonstrated efficacy. These include topical tacrolimus, as well as YAG and carbon dioxide laser treatments.^4-6

Although information is limited on rates of recurrence, circumcision is considered the treatment of choice and is usually curative.¹

Ointment does the trick for our patient

Our patient was treated with a single combined topical ointment consisting of nystatin and triamcinolone cream with zinc oxide. The lesion resolved completely after 10 days. We requested a urology consult so that a circumcision could be performed.

CORRESPONDENCE Matthew R. Noss, DO, MSEd, Fort Belvoir Community Hospital Family Medicine Clinic, 1st Floor, Eagle Pavilion, 9300 Dewitt Loop, Ft. Belvoir, VA 22060; [email protected]

A 63-YEAR-OLD MAN came to our clinic complaining of a rash on his penis. He indicated that the rash had been there for almost 2 years and that he’d seen 2 other doctors about it, but they’d been unable to make a diagnosis.

The patient said the rash was mildly painful and tender. He denied pain on urination, discharge, fever, malaise, or arthralgias. He also denied any sexual contact outside of his marriage and indicated that he had not been able to have intimate contact with his wife because of the problem.

The patient was uncircumcised and when the foreskin was retracted, a bright red erythematous nonscaly circumferential plaque was visible on the glans penis, spreading to the foreskin (FIGURE 1).

FIGURE 1
A nonscaly, circumferential plaque on the glans penis

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Zoon’s balanitis

We ordered a biopsy because we suspected that the cause of the rash was either erythroplasia of Queyrat (a premalignant condition also known as Bowen’s disease of the glans penis) or Zoon’s balanitis (plasma cell balanitis or balanitis circumscripta plasmacellularis). The biopsy report confirmed the diagnosis of Zoon’s balanitis and showed no signs of malignancy. The features of Zoon’s balanitis include epidermal atrophy, loss of rete ridges, spongiosis, and subepidermal plasma cell infiltrate without evidence of malignancy (FIGURE 2).

FIGURE 2
Dense plasmacytic infiltration underlying the mucosal epidermis

Condition affects older, uncircumcised men
Zoon’s balanitis is thought to be a benign condition that typically affects uncircumcised middle-aged to elderly men.^1,2 Worldwide prevalence among uncircumcised men is approximately 3%.² The etiology is unknown; it’s thought that this condition may be caused by friction, trauma, heat, lack of hygiene, exogenous or infectious agents, an IgE hypersensitivity, or a chronic infection with Mycobacterium smegmatis.^1,2

Typically, the appearance of the lesion precedes diagnosis by about one to 2 years.¹ The patient usually complains of mild pruritus and tenderness. Undergarments may be bloodstained.

The differential for penile lesions is extensive, and includes psoriasis, nummular eczema, candidiasis, herpes simplex, scabies, lichen sclerosus et atrophicus or lichen planus, syphilis, balanitis, and erythroplasia of Queyrat.

The lesion associated with Zoon’s balanitis is a solitary, glistening, shiny, red-to-orange plaque of the glans penis or prepuce of an uncircumcised male. Pinpoint erythematous spots or “cayenne pepper spots” may also be associated with this condition.

Patients with erythroplasia of Queyrat have either a solitary or multiple nonhealing erythematous plaques on the glans penis. These lesions may also affect the adjacent mucosal epithelium. As is true with Zoon’s balanitis, the typical patient is uncircumcised and middle-aged to elderly.^1,2

Presentations may be similar, but treatment differs

Because the treatments for Zoon’s balanitis and erythroplasia of Queyrat are different, a biopsy is imperative. Erythroplasia of Queyrat is a premalignant condition that is treated with topical fluorouracil or surgical excision.³ Treatment for Zoon’s balanitis consists of a topical corticosteroid with or without topical anticandidal agents and circumcision after the acute inflammation resolves.^1,2 (If a skin biopsy cannot be obtained in the clinic, the foreskin [if affected] can be sent for biopsy after the circumcision.)

If resolution is not seen with topical steroid treatment, other treatments have demonstrated efficacy. These include topical tacrolimus, as well as YAG and carbon dioxide laser treatments.^4-6

Although information is limited on rates of recurrence, circumcision is considered the treatment of choice and is usually curative.¹

Ointment does the trick for our patient

Our patient was treated with a single combined topical ointment consisting of nystatin and triamcinolone cream with zinc oxide. The lesion resolved completely after 10 days. We requested a urology consult so that a circumcision could be performed.

CORRESPONDENCE Matthew R. Noss, DO, MSEd, Fort Belvoir Community Hospital Family Medicine Clinic, 1st Floor, Eagle Pavilion, 9300 Dewitt Loop, Ft. Belvoir, VA 22060; [email protected]

Death follows a normal EKG

MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.

The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.

Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.

No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.

PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.

THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.

VERDICT $1.5 million Illinois verdict.

COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.

Kidney failure after multiple meds

A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.

PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.

THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.

VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.

COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.

Death follows a normal EKG

MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.

The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.

Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.

No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.

PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.

THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.

VERDICT $1.5 million Illinois verdict.

COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.

Kidney failure after multiple meds

A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.

PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.

THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.

VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.

COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.

Death follows a normal EKG

MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.

The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.

Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.

No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.

PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.

THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.

VERDICT $1.5 million Illinois verdict.

COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.

Kidney failure after multiple meds

A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.

PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.

THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.

VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.

COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.

The Centers for Disease Control and Prevention (CDC) recently released new recommendations for screening for hepatitis C virus (HCV) infection that include a one-time screening for everyone in the United States born between 1945 and 1965, regardless of risk.¹ These new recommendations are an enhancement of, but not a replacement for, the recommendations for HCV screening made in 1998, which called for screening those at high risk.²

HCV causes considerable morbidity and mortality in this country. Approximately 17,000 new infections occurred in 2010.¹ Between 2.7 and 3.9 million Americans (1%-1.5% of the population) are living with chronic HCV infection, and many do not know they are infected.¹ This lack of awareness appears to be due to a failure of both health care providers to offer testing to those at known risk and patients to either acknowledge or recall past high-risk behaviors.

Those at highest risk for HCV infection are current or past users of illegal injected drugs and recipients of a blood transfusion before 1992 (when HCV screening of the blood supply was instituted). Other risk factors are listed in TABLE 1.¹ Many of those with HCV infection do not report injection drug use or having received a transfusion prior to 1992, and they are not detected by current risk-based testing.

TABLE 1
Risk factors for HCV infection¹

Approximately three-fourths of those who acquire HCV are unable to clear the virus and become chronically infected.¹ Twenty percent of these individuals will develop cirrhosis and 5% will die from an HCV-related liver disease, such as decompensated cirrhosis or hepatocellular carcinoma (HCC).³

New treatments. In 2011, 2 protease inhibitor drugs, telaprevir and boceprevir, were approved for the treatment of HCV geno-type 1. These are the first generation of a class of drugs called direct-acting antiviral agents (DAAs). When a DAA is added to the standard therapy of ribavirin and pegylated interferon, the rate of viral clearance increases (from 44% to 75% for telaprevir and from 38% to 63% for boceprevir).¹ However, the adverse reactions caused by these new drugs can lead to a 34% rise in the rate at which patients stop treatment.¹ Twenty potential new HCV antivirals are in clinical trials, and it is expected that treatment recommendations will change rapidly as some of these are approved.

Does treatment improve long-term outcomes?

Clinical guidelines recommend antiviral treatment for anyone with HCV infection and biopsy evidence of bridging fibrosis, septal fibrosis, or cirrhosis.⁴

A look at Tx and all-cause mortality. Studies looking at patient-oriented outcomes such as all-cause mortality and incidence of HCC have been conducted with pegylated interferon and ribavirin, without the newer DAAs. The most commonly cited study assessed all-cause mortality in a large sample of veterans with multiple comorbidities.

Those who achieved a sustained virological response after treatment exhibited a reduction in all-cause mortality >50% compared with nonresponders. This endpoint included substantially lower rates of liver-related deaths and cirrhosis complicated by ascites, variceal bleeding, or encephalopathy.⁵ However, in such a nonrandom clinical trial, an improved outcome for responders could be due to their relatively good health, with fewer comorbid conditions, and other undetected biases. While this study attempted to control for such biases, it didn’t provide evidence that treating infection detected by screening a low-risk population would improve intermediate or long-term outcomes.

Observational studies look at carcinoma incidence. Twelve observational studies have addressed treatment effects on HCC incidence. They showed a 75% reduction in HCC rates in those who achieved viral clearance compared with those who did not.¹ Again, these studies did not compare treated and untreated patients in a controlled clinical trial; they looked only at treated individuals and compared the outcomes of responders and nonresponders.

HCV transmission research is lacking. The CDC found no studies in its evidence review that addressed the issue of HCV transmission. Nevertheless, the new recommendations state that HCV transmission was a critical factor in determining the strength of the recommendation for age cohort screening. It is expected that those who have a sustained viral response will be less likely to transmit the virus to others.

Why the 1945-1965 birth cohort?
The prevalence of HCV infection in those born between 1945 and 1965 is 3.25%, and three-fourths of all those with HCV infection in the United States are in this cohort. The FIGURE depicts the large difference in prevalence between this age group and others. Within 3 cohorts defined by date of birth (1945-1965, 1950-1970, and 1945-1970), the prevalence of HCV infection is twice as high in men than in women, and in black non-Hispanics than in white non-Hispanics and Mexican Americans. However, extending the birth cohort to those born through 1970 yields only a marginal difference in prevalence figures. The CDC justifies restricting the new universal screening recommendation to the 1945-1965 age group mainly on the results of focus groups in which the public identified this cohort as “baby boomers” who would likely adopt the recommendation.

FIGURE
Prevalence of hepatitis C virus antibody by year of birth¹

*National Health and Nutrition Examination Survey, United States, 1988–1994 and 1999–2002.

Two-step screening process
Screen individuals using a test for antibodies to HCV (anti-HCV). If the anti-HCV test result is positive, order a test for HCV nucleic acid that gives either a quantitative measure of viral load or a qualitative assessment of presence or absence of virus. If the confirmatory nucleic acid test result is negative, the individual does not have chronic HCV infection and is among the approximately 25% who clear the virus on their own. They do not need further testing or treatment.

What to tell infected patients

If the confirmatory test result is positive, presume the patient has HCV infection and offer the advice contained in TABLE 2.¹ Patients should undergo further assessment for possible chronic liver disease and, with the counsel of their physician, decide whether to initiate treatment. They should also take measures to protect the liver from further damage, such as reducing alcohol consumption, avoiding medication and herbal products that can damage the liver, maintaining an optimal weight, and receiving vaccines against hepatitis A and B, if still susceptible to these viruses. Finally, encourage patients to take steps to avoid transmission of HCV to others.

TABLE 2
Advice for your patients with HCV infection¹

The decision on whether to begin treatment immediately is complicated by the large number of new antivirals in development, which will be available in the near future and may be more effective with fewer adverse effects.

Lingering controversies
Given the lack of evidence of improved outcomes with HCV screening in the general population, it will be interesting to see how widely accepted the new CDC recommendations will be. The US Preventive Services Task Force is in the process of revising its HCV screening recommendations. Given the Task Force’s evidence-based methodology and the lack of evidence on the benefits and harms of screening those with no reported risks, there may be some differences with the new CDC recommendations.

If the CDC’s assumption proves correct—ie, that the benefits of treating high-risk populations will also occur with treating detected infection in the general population—and if the age cohort screening recommendation is fully implemented, 47,000 cases of HCC and 15,000 liver transplants will be prevented.¹

The Centers for Disease Control and Prevention (CDC) recently released new recommendations for screening for hepatitis C virus (HCV) infection that include a one-time screening for everyone in the United States born between 1945 and 1965, regardless of risk.¹ These new recommendations are an enhancement of, but not a replacement for, the recommendations for HCV screening made in 1998, which called for screening those at high risk.²

HCV causes considerable morbidity and mortality in this country. Approximately 17,000 new infections occurred in 2010.¹ Between 2.7 and 3.9 million Americans (1%-1.5% of the population) are living with chronic HCV infection, and many do not know they are infected.¹ This lack of awareness appears to be due to a failure of both health care providers to offer testing to those at known risk and patients to either acknowledge or recall past high-risk behaviors.

Those at highest risk for HCV infection are current or past users of illegal injected drugs and recipients of a blood transfusion before 1992 (when HCV screening of the blood supply was instituted). Other risk factors are listed in TABLE 1.¹ Many of those with HCV infection do not report injection drug use or having received a transfusion prior to 1992, and they are not detected by current risk-based testing.

TABLE 1
Risk factors for HCV infection¹

Approximately three-fourths of those who acquire HCV are unable to clear the virus and become chronically infected.¹ Twenty percent of these individuals will develop cirrhosis and 5% will die from an HCV-related liver disease, such as decompensated cirrhosis or hepatocellular carcinoma (HCC).³

New treatments. In 2011, 2 protease inhibitor drugs, telaprevir and boceprevir, were approved for the treatment of HCV geno-type 1. These are the first generation of a class of drugs called direct-acting antiviral agents (DAAs). When a DAA is added to the standard therapy of ribavirin and pegylated interferon, the rate of viral clearance increases (from 44% to 75% for telaprevir and from 38% to 63% for boceprevir).¹ However, the adverse reactions caused by these new drugs can lead to a 34% rise in the rate at which patients stop treatment.¹ Twenty potential new HCV antivirals are in clinical trials, and it is expected that treatment recommendations will change rapidly as some of these are approved.

Does treatment improve long-term outcomes?

Clinical guidelines recommend antiviral treatment for anyone with HCV infection and biopsy evidence of bridging fibrosis, septal fibrosis, or cirrhosis.⁴

A look at Tx and all-cause mortality. Studies looking at patient-oriented outcomes such as all-cause mortality and incidence of HCC have been conducted with pegylated interferon and ribavirin, without the newer DAAs. The most commonly cited study assessed all-cause mortality in a large sample of veterans with multiple comorbidities.

Those who achieved a sustained virological response after treatment exhibited a reduction in all-cause mortality >50% compared with nonresponders. This endpoint included substantially lower rates of liver-related deaths and cirrhosis complicated by ascites, variceal bleeding, or encephalopathy.⁵ However, in such a nonrandom clinical trial, an improved outcome for responders could be due to their relatively good health, with fewer comorbid conditions, and other undetected biases. While this study attempted to control for such biases, it didn’t provide evidence that treating infection detected by screening a low-risk population would improve intermediate or long-term outcomes.

Observational studies look at carcinoma incidence. Twelve observational studies have addressed treatment effects on HCC incidence. They showed a 75% reduction in HCC rates in those who achieved viral clearance compared with those who did not.¹ Again, these studies did not compare treated and untreated patients in a controlled clinical trial; they looked only at treated individuals and compared the outcomes of responders and nonresponders.

HCV transmission research is lacking. The CDC found no studies in its evidence review that addressed the issue of HCV transmission. Nevertheless, the new recommendations state that HCV transmission was a critical factor in determining the strength of the recommendation for age cohort screening. It is expected that those who have a sustained viral response will be less likely to transmit the virus to others.

Why the 1945-1965 birth cohort?
The prevalence of HCV infection in those born between 1945 and 1965 is 3.25%, and three-fourths of all those with HCV infection in the United States are in this cohort. The FIGURE depicts the large difference in prevalence between this age group and others. Within 3 cohorts defined by date of birth (1945-1965, 1950-1970, and 1945-1970), the prevalence of HCV infection is twice as high in men than in women, and in black non-Hispanics than in white non-Hispanics and Mexican Americans. However, extending the birth cohort to those born through 1970 yields only a marginal difference in prevalence figures. The CDC justifies restricting the new universal screening recommendation to the 1945-1965 age group mainly on the results of focus groups in which the public identified this cohort as “baby boomers” who would likely adopt the recommendation.

FIGURE
Prevalence of hepatitis C virus antibody by year of birth¹

*National Health and Nutrition Examination Survey, United States, 1988–1994 and 1999–2002.

Two-step screening process
Screen individuals using a test for antibodies to HCV (anti-HCV). If the anti-HCV test result is positive, order a test for HCV nucleic acid that gives either a quantitative measure of viral load or a qualitative assessment of presence or absence of virus. If the confirmatory nucleic acid test result is negative, the individual does not have chronic HCV infection and is among the approximately 25% who clear the virus on their own. They do not need further testing or treatment.

What to tell infected patients

If the confirmatory test result is positive, presume the patient has HCV infection and offer the advice contained in TABLE 2.¹ Patients should undergo further assessment for possible chronic liver disease and, with the counsel of their physician, decide whether to initiate treatment. They should also take measures to protect the liver from further damage, such as reducing alcohol consumption, avoiding medication and herbal products that can damage the liver, maintaining an optimal weight, and receiving vaccines against hepatitis A and B, if still susceptible to these viruses. Finally, encourage patients to take steps to avoid transmission of HCV to others.

TABLE 2
Advice for your patients with HCV infection¹

The decision on whether to begin treatment immediately is complicated by the large number of new antivirals in development, which will be available in the near future and may be more effective with fewer adverse effects.

Lingering controversies
Given the lack of evidence of improved outcomes with HCV screening in the general population, it will be interesting to see how widely accepted the new CDC recommendations will be. The US Preventive Services Task Force is in the process of revising its HCV screening recommendations. Given the Task Force’s evidence-based methodology and the lack of evidence on the benefits and harms of screening those with no reported risks, there may be some differences with the new CDC recommendations.

If the CDC’s assumption proves correct—ie, that the benefits of treating high-risk populations will also occur with treating detected infection in the general population—and if the age cohort screening recommendation is fully implemented, 47,000 cases of HCC and 15,000 liver transplants will be prevented.¹

The Centers for Disease Control and Prevention (CDC) recently released new recommendations for screening for hepatitis C virus (HCV) infection that include a one-time screening for everyone in the United States born between 1945 and 1965, regardless of risk.¹ These new recommendations are an enhancement of, but not a replacement for, the recommendations for HCV screening made in 1998, which called for screening those at high risk.²

HCV causes considerable morbidity and mortality in this country. Approximately 17,000 new infections occurred in 2010.¹ Between 2.7 and 3.9 million Americans (1%-1.5% of the population) are living with chronic HCV infection, and many do not know they are infected.¹ This lack of awareness appears to be due to a failure of both health care providers to offer testing to those at known risk and patients to either acknowledge or recall past high-risk behaviors.

Those at highest risk for HCV infection are current or past users of illegal injected drugs and recipients of a blood transfusion before 1992 (when HCV screening of the blood supply was instituted). Other risk factors are listed in TABLE 1.¹ Many of those with HCV infection do not report injection drug use or having received a transfusion prior to 1992, and they are not detected by current risk-based testing.

TABLE 1
Risk factors for HCV infection¹

Approximately three-fourths of those who acquire HCV are unable to clear the virus and become chronically infected.¹ Twenty percent of these individuals will develop cirrhosis and 5% will die from an HCV-related liver disease, such as decompensated cirrhosis or hepatocellular carcinoma (HCC).³

New treatments. In 2011, 2 protease inhibitor drugs, telaprevir and boceprevir, were approved for the treatment of HCV geno-type 1. These are the first generation of a class of drugs called direct-acting antiviral agents (DAAs). When a DAA is added to the standard therapy of ribavirin and pegylated interferon, the rate of viral clearance increases (from 44% to 75% for telaprevir and from 38% to 63% for boceprevir).¹ However, the adverse reactions caused by these new drugs can lead to a 34% rise in the rate at which patients stop treatment.¹ Twenty potential new HCV antivirals are in clinical trials, and it is expected that treatment recommendations will change rapidly as some of these are approved.

Does treatment improve long-term outcomes?

Clinical guidelines recommend antiviral treatment for anyone with HCV infection and biopsy evidence of bridging fibrosis, septal fibrosis, or cirrhosis.⁴

A look at Tx and all-cause mortality. Studies looking at patient-oriented outcomes such as all-cause mortality and incidence of HCC have been conducted with pegylated interferon and ribavirin, without the newer DAAs. The most commonly cited study assessed all-cause mortality in a large sample of veterans with multiple comorbidities.

Those who achieved a sustained virological response after treatment exhibited a reduction in all-cause mortality >50% compared with nonresponders. This endpoint included substantially lower rates of liver-related deaths and cirrhosis complicated by ascites, variceal bleeding, or encephalopathy.⁵ However, in such a nonrandom clinical trial, an improved outcome for responders could be due to their relatively good health, with fewer comorbid conditions, and other undetected biases. While this study attempted to control for such biases, it didn’t provide evidence that treating infection detected by screening a low-risk population would improve intermediate or long-term outcomes.

Observational studies look at carcinoma incidence. Twelve observational studies have addressed treatment effects on HCC incidence. They showed a 75% reduction in HCC rates in those who achieved viral clearance compared with those who did not.¹ Again, these studies did not compare treated and untreated patients in a controlled clinical trial; they looked only at treated individuals and compared the outcomes of responders and nonresponders.

HCV transmission research is lacking. The CDC found no studies in its evidence review that addressed the issue of HCV transmission. Nevertheless, the new recommendations state that HCV transmission was a critical factor in determining the strength of the recommendation for age cohort screening. It is expected that those who have a sustained viral response will be less likely to transmit the virus to others.

Why the 1945-1965 birth cohort?
The prevalence of HCV infection in those born between 1945 and 1965 is 3.25%, and three-fourths of all those with HCV infection in the United States are in this cohort. The FIGURE depicts the large difference in prevalence between this age group and others. Within 3 cohorts defined by date of birth (1945-1965, 1950-1970, and 1945-1970), the prevalence of HCV infection is twice as high in men than in women, and in black non-Hispanics than in white non-Hispanics and Mexican Americans. However, extending the birth cohort to those born through 1970 yields only a marginal difference in prevalence figures. The CDC justifies restricting the new universal screening recommendation to the 1945-1965 age group mainly on the results of focus groups in which the public identified this cohort as “baby boomers” who would likely adopt the recommendation.

FIGURE
Prevalence of hepatitis C virus antibody by year of birth¹

*National Health and Nutrition Examination Survey, United States, 1988–1994 and 1999–2002.

Two-step screening process
Screen individuals using a test for antibodies to HCV (anti-HCV). If the anti-HCV test result is positive, order a test for HCV nucleic acid that gives either a quantitative measure of viral load or a qualitative assessment of presence or absence of virus. If the confirmatory nucleic acid test result is negative, the individual does not have chronic HCV infection and is among the approximately 25% who clear the virus on their own. They do not need further testing or treatment.

What to tell infected patients

If the confirmatory test result is positive, presume the patient has HCV infection and offer the advice contained in TABLE 2.¹ Patients should undergo further assessment for possible chronic liver disease and, with the counsel of their physician, decide whether to initiate treatment. They should also take measures to protect the liver from further damage, such as reducing alcohol consumption, avoiding medication and herbal products that can damage the liver, maintaining an optimal weight, and receiving vaccines against hepatitis A and B, if still susceptible to these viruses. Finally, encourage patients to take steps to avoid transmission of HCV to others.

TABLE 2
Advice for your patients with HCV infection¹

The decision on whether to begin treatment immediately is complicated by the large number of new antivirals in development, which will be available in the near future and may be more effective with fewer adverse effects.

Lingering controversies
Given the lack of evidence of improved outcomes with HCV screening in the general population, it will be interesting to see how widely accepted the new CDC recommendations will be. The US Preventive Services Task Force is in the process of revising its HCV screening recommendations. Given the Task Force’s evidence-based methodology and the lack of evidence on the benefits and harms of screening those with no reported risks, there may be some differences with the new CDC recommendations.

If the CDC’s assumption proves correct—ie, that the benefits of treating high-risk populations will also occur with treating detected infection in the general population—and if the age cohort screening recommendation is fully implemented, 47,000 cases of HCC and 15,000 liver transplants will be prevented.¹