acute psychosis“>American Journal of Emergency Medicine 36 (2018) 2076-2077

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Meningitis presenting as acute psychosis in the ED: Speciality collaboration and rethinking the generalizability to real-world practice

Hidetaka Tamune?

Department of Cellular Neurobiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Japan

Department of Neuropsychiatry, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan

A R T I C L E I N F O

Article history:

Received 17 August 2018

Received in revised form 18 August 2018

Accepted 20 August 2018

Keywords:

Generalizability External validity Meningitis Psychosis

Psychotic symptoms Screening tool

The term “psychosis” is derived from the Greek word for abnormal condition of the mind [1]. Due to the difficulty of obtaining a medical history or physical findings from patients with psychosis, it’s not always clear in the emergency department (ED) how to manage such patients. While the term psychosis generally reminds physicians of a psychiatric disease such as schizophrenia, Laher et al. [2] in this issue demonstrated that, of 159 consecutive patients with acute psychosis, meningitis was diagnosed in 28 patients (18.3%) among 153 who underwent a lumbar puncture. The present study seems the largest study to focus on distinguishing meningitis from patients with acute psychosis.

Based on the study of Laher et al. [2], none of the following factors, either alone or in combination, were able to rule out meningitis: the ab- sence of (a) clinical features of meningitis, (b) Visual hallucinations,

(c) pyrexia N37.5 ?C, (d) CRP N10 mg/L, (e) HIV seropositive status or the presence of (f) Illicit substances on urinalysis. However, the negative predictive values of “the presence of one or more of four variables” exceeded 95%, which may indicate its utility as a screening tool.

Perhaps it’s time to reassess the generalizability (external validity) of studies dealing with meningitis. Although up to now much research

? The author received no support, grant, or funding for this editorial.

* Department of Cellular Neurobiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan

E-mail address: tamune-tky@umin.ac.jp.

has focused on methods of detecting meningitis early, none of the find- ings have been definitive. For example, Jolt accentuation of headache (JA) reportedly had 97% sensitivity and 60% specificity for CSF pleocytosis [3], and its use became widespread after the finding was cited by JAMA [4]. However, the claims about its utility are now being questioned [5-8].

We previously demonstrated that JA was not a reliable method for patients with Altered mental status [6,9], and AMS/delirium screening in ED is currently drawing increasing attention [10-16]. Screening tools can help physicians decide whether to perform a lumbar puncture although complete certainty with these methods is inherently impossible. Thus, as suggested in this study [2], physicians can adopt a low threshold to perform a lumbar puncture in patients with acute psychosis.

The CSF/blood glucose ratio may serve as a good indicator of (bacterial) meningitis [17-19], and we argued that the ratio is par- ticularly useful in a limited resource setting [20]. However, its sen- sitivity and specificity as assessed in this study [2] were relatively low, partly due to the large number of patients with tuberculous meningitis. Furthermore, this study indicated that when examin- ing HIV-positive patients (or more broadly, Immunocompromised patients), clinicians need to be aware of the possibility that the CSF/blood glucose ratio cannot decrease even if the patient is suf- fering from Bacterial meningitis [21,22].

Extreme caution is required when attempting to generalize the find- ings of meningitis studies for application to real-world clinical practice. Non-negligible factors may include causative pathogens, setting, and patient background.

Laher et al. [2] highlight the necessity of assessment of AMS, objec- tive findings, and physical disorders in patients with acute psychosis be- fore they are transferred to the psychiatric department. On the other hand, psychiatrists also need to be aware of possible physical causes in patients with acute psychosis. The study published in this issue of AJEM reinforces the value of greater collaboration between the ED phy- sicians and psychiatrists in assessing acute psychosis.

Acknowledgment

I thank Mr. James Robert Valera for his assistance in editing this manuscript.

https://doi.org/10.1016/j.ajem.2018.08.058

0735-6757/(C) 2018

H. Tamune / American Journal of Emergency Medicine 36 (2018) 2076–2077 2077

References

1. Lieberman JA, First MB. Psychotic disorders. N Engl J Med 2018;379(3):270-80.
2. Laher et al. First-presentation with psychotic features to the Emergency Depart- ment: meningitis or not, that is the question. Am J Emerg Med 2018;55(1):78-86.
3. Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache 1991;31(3):167-71.
4. Attia J, Hatala R, Cook DJ, Wong JG. The rational clinical examination. Does this adult patient have acute meningitis? JAMA 1999;282(2):175-81.
5. Waghdhare S, Kalantri A, Joshi R, Kalantri S. Accuracy of physical signs for detecting meningitis: a hospital-based diagnostic accuracy study. Clin Neurol Neurosurg 2010; 112(9):752-7.
6. Tamune H, Takeya H, Suzuki W, Tagashira Y, Kuki T, Nakamura M. Absence of jolt ac- centuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med 2013;31(11):1601-4.
7. Nakao JH, Jafri FN, Shah K, Newman DH. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med 2014;32 (1):24-8.
8. Sato R, Kuriyama A, Luthe SK. Can we rule out meningitis from negative jolt accen- tuation? A retrospective cohort study. Headache 2017;57(4):586-92.
9. Tamune H, Kuki T, Kashiyama T, Uchihara T. Does this adult patient with jolt accen- tuation of headache have acute meningitis? Headache, (in press).
10. Tamune H, Yasugi D. How can we identify patients with delirium in the emergency department?: a review of available screening and diagnostic tools. Am J Emerg Med 2017;35(9):1332-4.
11. Grossmann FF, Hasemann W, Kressig RW, Bingisser R, Nickel CH. Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older ED pa- tients. Am J Emerg Med 2017;35(9):1324-6.
12. Han JH, Wilson A, Schnelle JF, Dittus RS, Ely EW. An evaluation of single question de- lirium screening tools in older emergency department patients. Am J Emerg Med 2018;36(7):1249-52.
13. Hasemann W, Grossmann FF, Stadler R, Bingisser R, Breil D, Hafner M, et al. Screen- ing and detection of delirium in older ED patients: performance of the modified Con- fusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool. Intern Emerg Med 2017 Dec 30 (Available online. [PMID:29290048]).
14. Quispel-Aggenbach DWP, Holtman GA, Zwartjes HAHT, Zuidema SU, Luijendijk HJ. Attention, arousal and other rapid bedside screening instruments for delirium in older patients: a systematic review of test accuracy studies. Age Ageing 2018 Apr 25 (Available online. [PMID:29697753]).
15. Baten V, Busch HJ, Busche C, Schmid B, Heupel-Reuter M, Perlov E, et al. Validation of the brief confusion assessment method for screening delirium in elderly medical pa- tients in a German emergency department. Acad Emerg Med 2018 May 8 (Available online. [PMID:29738102]).
16. Gagne AJ, Voyer P, Boucher V, Nadeau A, Carmichael PH, Pelletier M, et al. Performance of the French version of the 4AT for screening the elderly for delirium in the emer- gency department. CJEM 2018 May 17:1-8 (Available online. [PMID:29769154]).
17. Tamune H, Takeya H, Suzuki W, Tagashira Y, Kuki T, Honda H, et al. Cerebrospinal fluid/blood glucose ratio as an indicator for bacterial meningitis. Am J Emerg Med 2014;32(3):263-6.
18. Rousseau G, Asmolov R, Grammatico-Guillon L, Auvet A, Laribi S, Garot D, et al. Rapid detection of bacterial meningitis using a point-of-care glucometer. Eur J Emerg Med 2017 Aug 10 (Available online. [PMID:28799985]).
19. Baud MO, Vitt JR, Robbins NM, et al. Pleocytosis is not fully responsible for low CSF glucose in meningitis. Neurol Neuroimmunol Neuroinflamm 2017;5:e425.
20. Tamune H, Kuki T. Cerebrospinal fluid/blood glucose Point-of-care testing ratio for

    diagnosing bacterial meningitis in a limited medical resource setting. Eur J Emerg Med, (in press).

    Sato R, Nasu M, Yagi R, Kitahara Y. Streptococcus pneumoniae meningitis without pleocytosis of the cerebrospinal fluid. Am J Emerg Med 2016;34(5):941.

21. Tamune H, Kuki T. CSF/blood glucose ratio and bacterial meningitis without

    pleocytosis in a potentially immunocompromised host. Am J Emerg Med 2016;34: 922.