Abstract Title Psychosis Due to B12-Deficiency Followed by Steroid-Induced Psychosis Without Psychiatric History

Background Both B12 deficiency and corticosteroid use can present clinically with neuropsychiatric manifestations like a manic episode, including personality changes, poor concentration, memory impairment, delirium and psychosis. Underlying mechanisms for such mental changes in B12 deficiency include alterations in one carbon metabolism, genetic vulnerability, and variability in folate metabolism. Neuropsychiatric symptoms of B12 deficiency typically improve with B12 supplementation, but may lead to irreversible cognitive impairment. For Corticosteroid-induced psychotic disorder (CIPD), there appears to be a dose-dependent relationship with prednisone doses greater than 40 mg per day and psychiatric manifestations. Termination of the steroid typically leads to neuropsychiatric symptom resolution within two weeks, but can last from days to months. Severity of symptoms can be minimized with antipsychotics or mood-stabilizing medications. This case discusses a rare scenario in which a patient with no known psychiatric history experiences two episodes of psychosis caused by different organic causes (B12 deficiency, corticosteroid use) within 7 months.

Case Presentation A 61-year-old male with a past medical history of hypertension and hyperlipidemia, and no prior psychiatric history presents to the ED for mania-like symptoms including elevated mood, decreased need for sleep, pressured speech, grandiosity, and distractibility. Lab results revealed severely low B12 of 50 mcg/ml, and the patient was discharged with a diagnosis of Psychotic Disorder due to another Medical Condition. In the subsequent weeks, the patient’s psychiatric symptoms resolved with consistent B12 supplementation. Six months later, the patient presented outpatient for symptoms of left ear labyrinthitis and was prescribed 60mg prednisone daily for 20 days. 14 days into the course, the patient began to experience similar mania-like symptoms and presented to the ED. Laboratory workup was unremarkable including normal B12 levels, and he was transferred to inpatient psychiatry. The patient was diagnosed with Steroid-Induced Psychosis and started on Depakote 500mg BID and Zyprexa 10mg nightly. He was discharged 2 days later after considerable improvement in severity of symptoms

Discussion Additional study of organic psychoses is needed to understand how to treat symptoms for acute stabilization vs. long-term prevention and describe the underlying predispositions to and mechanisms of psychotic symptoms in each context. There is no known link between prior psychosis due to B12 deficiency and risk of CIPD. More research is needed to explain the etiology of episodic neuropsychiatric symptoms in patients with no known psychiatric history, and whether primary psychiatric disorders such as Bipolar I better explain the symptoms.