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Resolution of Othello-like syndrome following ventricular shunting in a post traumatic normal pressure hydrocephalus subject

Fernando Campos Gomes Pinto1, Gabriela Stump2, Leandro Valiengo3, Matheus Fernandes de Oliveira1

1 Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery of the Institute of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HCFMUSP), São Paulo, SP, Brazil.

2 Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (IPq-HCFMUSP), São Paulo, SP, Brazil.

3 Neuroscience Laboratory – LIM 27, Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo (IPq-HCFMUSP), São Paulo, SP, Brazil.

Pinto FCG et al. / Arch Clin Psychiatry. 2016;43(5):132-3

Received: 9/5/2016 – Accepted: 9/20/2016

DOI: 10.1590/0101-60830000000098

Address for correspondence: Matheus Fernandes de Oliveira. Rua Loefgreen, 700, ap. 103, Vila Clementino – 04040-000 – São Paulo, SP, Brazil. E-mail: mafernoliv@yahoo.com.br

Dear Editor,

Normal pressure hydrocephalus (NPH) is a syndrome characterized by urinary incontinence, gait disturbance and dementia plus dilation of ventricular system due to disturbance of cerebrospinal fluid (CSF) circulation1-4. There is wide scientifical evidence pointing association between NPH and psychiatric symptoms1-4.

Othello syndrome (OS) is a content-specific jealousy delusion characterized by fixed false belief that one’s partner has been or is being unfaithful5-10. We report an unusual case of NPH associated with Othello-like syndrome5-10, and complete improvement of psychiatric symptoms after proper neurosurgical treatment.

Figure 1. (A) Skull CT after trauma, revealing small ventricles and small subarachnoid hemorrhages, especially in left hemisphere. (B) Skull CT after psychiatric symptoms, revealing hydrocephalus. (C) SPECT image, disclosing almost symmetrical perfusion in whole brain. (D) Skull CT after shunting, with reduction of ventricular sizes followed by improved psychiatric symptoms.

Figure 1. (A) Skull CT after trauma, revealing small ventricles and small subarachnoid hemorrhages, especially in left hemisphere. (B) Skull CT after psychiatric symptoms, revealing hydrocephalus. (C) SPECT image, disclosing almost symmetrical perfusion in whole brain. (D) Skull CT after shunting, with reduction of ventricular sizes followed by improved psychiatric symptoms.

Case description

We report a case of a 66-year-old white man attending to emergency room evaluation in September 2015. In a rainy day, he was driving his car and a tree had fallen just over him. He was conducted to hospital, with preserved consciousness but complaining of headache. His previous medical history was eventless. A full trauma investigation was done without any finding, except for a mild brain traumatic injury, characterized by headache and subarachnoid hemorrhages in skull computed tomography (CT) (Figure 1A).

Initially, patient was submitted only to neurological observation and was discharged after 4 days, with preserved neurological examination.

During hospitalization, he started to behave with aggressivity and jealous with his wife. At home, he continued to behave with aggressivity and suspicion, imagining that his wife was cheating him with anybody who came to his house to visit him during recovery.

First psychiatric evaluation raised the hypothesis of jealous delusions and a trial was done with quetiapine (up to 600 mg) without any results. The second trial with risperidone (up to 6 mg) has also failed. In the follow-up medical consultation this behavior became clear and a control CT and single photon emission cintilography (SPECT) were performed after one month of trauma, disclosing enlarged ventricles compared to post traumatic CT (Figures 1B and 1C). SPECT did not identify clearly a hypoperfusional region.

Then, he was submitted to surgery two months after initial trauma (Figure 1D). Postoperative period was unremarkable, and his jealousy symptoms decreased promptly. Nowadays, six months after trauma, he has returned to routine daily activities and is symptom free.

Discussion

Our case illustrates the improvement of OS after shunting a post traumatic NPH patient. Oliveira et al. showed that up to 70% of patients with NPH may present neuropsychiatric symptoms, which may be from metabolic impairments in frontal lobe, basal ganglia and thalamus, all of which can be involved in pathophysiology of OS1-10.

OS is a content-specific jealousy delusion characterized by fixed false belief that one’s partner has been or is being unfaithful8-10. This delusion can range from mild to severe cases, with negative impact in social interaction and even risk of violence due to extreme jealousy8-10. Some anecdotal cases were described after frontal pathologies like tumors, surgeries, frontal strokes, traumatic injuries and use of medications (ropinirole, pramipexole, zonisamide).

In our case, there was probably a link between initial trauma, development of hydrocephalus and onset of psychiatric symptoms. After shunting, a clear improvement in symptoms was observed.

References

  1. Oliveira MF, Oliveira JR, Rotta JM, Pinto FC. Psychiatric symptoms are present in most of the patients with idiopathic normal pressure hydrocephalus. Arq Neuropsiquiatr. 2014;72(6):435-8.
  2. de Oliveira MF, Pinto FC, Rotta JM. Normal pressure hydrocephalus in a professional athlete: a model of brain functional reserve. J Neuropsychiatry Clin Neurosci. 2014;26(2):E39-40.
  3. Oliveira MF, Saad F, Reis RC, Rotta JM, Pinto FC. Programmable valve represents an efficient and safe tool in the treatment of idiopathic normal-pressure hydrocephalus patients. Arq Neuropsiquiatr. 2013;71(4):229-36.
  4. Pinto FC, Saad F, de Oliveira MF, Pereira RM, de Miranda FL, Tornai JB, et al. Role of endoscopic third ventriculostomy and ventriculoperitoneal shunt in idiopathic normal pressure hydrocephalus: preliminary results of a randomized clinical trial. Neurosurgery. 2013;72(5):845-53.
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