Polycytemia vera presenting as sudden-onset cognitive impairment

Neuropsychiatric Derangement by Polycythemia Vera: A Case Report of an Unexpected Disease Presentation and Review of the Literature

Cerebral infarction as well as other thromboses, headaches, and visual complaints are well-known symptoms of polycythemia vera. However, chorea and neuropsychiatric disturbances are less recognized consequences of this chronic disease. Whereas chorea is a rare but acknowledged symptom of polycythemia vera, neuropsychiatric symptoms have only sporadically been reported. We depict 2 patients with an unusual presentation of polycythemia vera. Our first patient presented with right-sided hemiballism and psychosis, and the second patient had a long diagnostic trajectory of unexplained chorea. In both cases diagnosis of JAK2 positive polycythemia vera was established, and in both cases remarkable recovery occurred after the initiation of phlebotomies. The underlying pathophysiology of these symptoms has not been clearly elucidated. Because of the unfamiliarity of the link between especially neuropsychiatric symptoms and polycythemia, current reported numbers are probably an underestimation. Benefit of treatment appears to be large. We seek to create more awareness among physicians about this phenomenon.

Polycythämia vera in der differenzialdiagnostischen Abklärung kognitiver Defizite

Anamnese Es erfolgt die Aufnahme einer 82-jährigen Patientin zur weiteren Abklärung zunehmender kognitiver Defizite und Gangunsicherheit.

Diagnostik und Befunde In der durchgeführten Computertomografie des Kopfes zeigten sich die Zeichen einer fortgeschrittenen subkortikalen arteriosklerotischen Enzephalopathie (SAE). Laborchemisch fiel ein erhöhter Hämoglobinwert von 19,9 g/dl auf. Bei zusätzlicher Mutation in der JAK-2-Analyse wurde die Diagnose einer Polycythämia vera (Pv) gestellt. Nach Aderlass-Therapie zeigte sich eine Verbesserung der Kognition.

Diskussion Die progredienten kognitiven Defizite sind bei vorbestehender SAE im Zusammenhang mit der neu diagnostizierten Pv zu sehen. Nach entsprechender Therapie der Pv ist auch langfristig eine Besserung der Kognition zu beobachten, sodass in diesem Fallbericht die Wichtigkeit einer Abklärung sekundärer, potenziell behandelbarer Ursachen von kognitiven Defiziten hervorgehoben wird.

An unusual psychiatric presentation of polycythaemia 'Difficulties lie in our habits of thought rather than in the nature of things' Andre Tardieu

Psychiatric symptoms are not always best explained in the context of psychological stress. The same mental, emotional and behavioural changes also arise from various medical conditions. For a clinician this dual origin of psychiatric symptoms creates an ongoing diagnostic challenge. Our patient is a 50-year-old gentleman who had been working in a company for around 33 years and always had good appraisals. He presented to mental health services with a 5-year history of persecutory beliefs, convinced that his employers were out to damage his reputation. Apart from a diagnosis of polycythaemia, a few months before the onset of abnormal beliefs, there is no personal or family history of psychiatric disorder or medical illness. His delusions did not respond to conventional treatment with psychotropic medication possibly due to non-adherence because of side effects. However, a series of venesections lead to an improvement in mental state.