Noncontrast computed tomography scan of the head and subsequent magnetic resonance imaging were performed and showed no acute changes. Differential diagnosis included metabolic derangement, encephalopathy, or delirium, which could be secondary to his long-standing history of illicit substance abuse. The full physical examination was otherwise unremarkable. No neurologic deficits were documented however, the examining physician was unable to assess muscle strength, gait, or cerebellar testing because the patient did not cooperate with the physical examination. He was disoriented to person and time, but aware and oriented to place. Initially, he was noted to have a mild tremor on bilateral upper extremities and to be looking toward the ceiling as if he were seeing things however, he was nonverbal. At presentation to the emergency department, the patient’s vital signs were within normal limits except for a blood pressure of 167/106 mm Hg. He has had 29 prior psychiatric hospitalizations, mainly related to his continuous substance abuse. His past medical history was significant for hypertension and bipolar disorder, which were well maintained with metoprolol and risperidone, respectively. His Montreal Cognitive Assessment (MoCA English version, score was 3/30 and he was giving 3- and 4-digit numbers as his phone number, which was a substantial change from his baseline. He demonstrated disorganized thoughts, disorganized behavior, and psychomotor retardation. He was refusing to eat and did not sleep at night prior to his presentation to the emergency department. A 49-year-old white male patient of a psychiatric hospital was transferred to the emergency department for complaints of altered mental status. 2Our case presents a patient with severe cognitive decline in the setting of a folate deficiency.Ĭase report. Homocysteine has even been linked to a higher risk of cognitive decline and Alzheimer’s disease and a 5-fold increase in the rate of brain atrophy. 1 A deficiency of vitamin B 12 or folate leads to an increased level of homocysteine, a highly toxic metabolite to neural and vascular development. 1 Many individuals with an underlying vitamin B 12 deficiency are labeled with other psychiatric diagnoses including major depressive disorder, bipolar disorder, and panic disorder. 1 Hematologic manifestations can include a megaloblastic, macrocytic anemia. To the Editor: Vitamin B 12 and folate deficiencies can result from inadequate intake, impaired absorption, or increased requirement, or the cause can be multifactorial such as in the setting of chronic alcoholism. Brief Reversible Psychosis and Altered Mental Status in a Patient With Folate Deficiency: A Case Report
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