Hypertensive Emergency Manifesting as Echophenomenon: A Revealing Exploration
Location
D.P. Culp Center Ballroom
Start Date
4-5-2024 9:00 AM
End Date
4-5-2024 11:30 AM
Poster Number
78
Name of Project's Faculty Sponsor
VENKATA VEDANTAM
Faculty Sponsor's Department
Internal Medicine
Competition Type
Competitive
Type
Poster Presentation
Presentation Category
Health
Abstract or Artist's Statement
Introduction: Echolalia, palilalia, echopraxia are abnormal verbal and postural behaviors, generally reported in encephalopathy, frontal lobe epilepsy, autism spectrum disorders and other neurological and psychiatric disorders. We present an unusual case of a patient with acute onset of these symptoms in the setting of hypertensive emergency. Case: A 53-year-old female with well-controlled Multiple Sclerosis; not on any disease modifying medications, benign pituitary gland neoplasm, and untreated hypertension, presented to the emergency department due to altered mental status which led to a car accident and subsequent arrest for suspected intoxication. Patient’s medications included Baclofen, gabapentin, nortriptyline, trazodone, and duloxetine. On arrival, despite being awake and alert, she exhibited hypervigilance, compulsive phrase repetition, and mimicking the facial expressions of people she was conversing with. She was found to have elevated blood pressure (187/102 mmHg). Urine and extended serum drug screens were negative, and all her other labs including electrolytes, liver and kidney function were normal. Magnetic resonance of her head was normal except for nonspecific white matter changes and electroencephalogram showed diffuse slowing of brain waves consistent with encephalopathy. The patient was diagnosed with hypertensive encephalopathy manifesting as echolalia, echopraxia, and palilalia and was started on Nicardipine Infusion which resolved her symptoms, and she returned to baseline within 24 hours. No prior episodes were reported. The patient was discharged after intensifying her outpatient blood pressure medication regimen. Discussion: Echolalia is described as nonspecific repetition of words and phrases, Echopraxia is the automatic imitation of the actions of others. Palilalia is described as a compulsive reiteration of utterances in a context of increasing rate and decreasing loudness which occurs in disorders affecting basal ganglia and frontal lobe. These phenomena can be acute or chronic and they are usually associated with both structural and functional neurological disorders. Echolalia is commonly seen in autism spectrum disorder, encephalitis, Tourette Syndrome, Pick disease (Frontotemporal dementia), schizophrenia, post epileptic status, stroke, and aphasia. In our case, these phenomena are temporally correlated to the acute hypertensive emergency and resolved completely on addressing the underlying hypertensive emergency. Hypertensive encephalopathy typically presents with generalized symptoms including fatigue, nausea, vomiting, and headaches. However, more severe neurological symptoms including seizures, vision loss, personality changes, and loss of consciousness have been reported. Although echo-phenomenon as a postictal phenomenon has been described in the literature, it has not been described as a manifestation of hypertensive encephalopathy and ours is the first case. It is also possible that our patient might have sustained a seizure in the setting of hypertensive encephalopathy and the echo-phenomenon could well be a manifestation of subsequent postictal state. Irrespective of its manifestation, if left untreated, hypertensive encephalopathy can lead to cerebral edema, end-organ damage, and coma. While there is no reported evidence of echolalia being a clear symptom of hypertensive encephalopathy, it could be a lesser-known, unreported side effect that requires additional research and studies. This case highlights the importance of considering hypertensive encephalopathy as a differential diagnosis in patients presenting with unusual neurological symptoms.
Hypertensive Emergency Manifesting as Echophenomenon: A Revealing Exploration
D.P. Culp Center Ballroom
Introduction: Echolalia, palilalia, echopraxia are abnormal verbal and postural behaviors, generally reported in encephalopathy, frontal lobe epilepsy, autism spectrum disorders and other neurological and psychiatric disorders. We present an unusual case of a patient with acute onset of these symptoms in the setting of hypertensive emergency. Case: A 53-year-old female with well-controlled Multiple Sclerosis; not on any disease modifying medications, benign pituitary gland neoplasm, and untreated hypertension, presented to the emergency department due to altered mental status which led to a car accident and subsequent arrest for suspected intoxication. Patient’s medications included Baclofen, gabapentin, nortriptyline, trazodone, and duloxetine. On arrival, despite being awake and alert, she exhibited hypervigilance, compulsive phrase repetition, and mimicking the facial expressions of people she was conversing with. She was found to have elevated blood pressure (187/102 mmHg). Urine and extended serum drug screens were negative, and all her other labs including electrolytes, liver and kidney function were normal. Magnetic resonance of her head was normal except for nonspecific white matter changes and electroencephalogram showed diffuse slowing of brain waves consistent with encephalopathy. The patient was diagnosed with hypertensive encephalopathy manifesting as echolalia, echopraxia, and palilalia and was started on Nicardipine Infusion which resolved her symptoms, and she returned to baseline within 24 hours. No prior episodes were reported. The patient was discharged after intensifying her outpatient blood pressure medication regimen. Discussion: Echolalia is described as nonspecific repetition of words and phrases, Echopraxia is the automatic imitation of the actions of others. Palilalia is described as a compulsive reiteration of utterances in a context of increasing rate and decreasing loudness which occurs in disorders affecting basal ganglia and frontal lobe. These phenomena can be acute or chronic and they are usually associated with both structural and functional neurological disorders. Echolalia is commonly seen in autism spectrum disorder, encephalitis, Tourette Syndrome, Pick disease (Frontotemporal dementia), schizophrenia, post epileptic status, stroke, and aphasia. In our case, these phenomena are temporally correlated to the acute hypertensive emergency and resolved completely on addressing the underlying hypertensive emergency. Hypertensive encephalopathy typically presents with generalized symptoms including fatigue, nausea, vomiting, and headaches. However, more severe neurological symptoms including seizures, vision loss, personality changes, and loss of consciousness have been reported. Although echo-phenomenon as a postictal phenomenon has been described in the literature, it has not been described as a manifestation of hypertensive encephalopathy and ours is the first case. It is also possible that our patient might have sustained a seizure in the setting of hypertensive encephalopathy and the echo-phenomenon could well be a manifestation of subsequent postictal state. Irrespective of its manifestation, if left untreated, hypertensive encephalopathy can lead to cerebral edema, end-organ damage, and coma. While there is no reported evidence of echolalia being a clear symptom of hypertensive encephalopathy, it could be a lesser-known, unreported side effect that requires additional research and studies. This case highlights the importance of considering hypertensive encephalopathy as a differential diagnosis in patients presenting with unusual neurological symptoms.