A 28-year-old man working in a local factory was admitted to the Department of Medicine with the diagnosis of acute dengue infection from where he was referred to the Psychiatry outpatient department of the University College of Medical Sciences and associated Guru Tegh Bahadur Hospital with the complaint of altered behavior.
Detailed psychiatric evaluation was performed. There was reported history of talking more than usual, feeling happy, increased activity, increased self-confidence, decreased need for sleep, and food, irritability, outbursts of aggression with grandiosity for a period of 5 days. Three days prior to onset of psychiatric illness, he developed fever (40.6 C) associated with severe headache, transient spells of altered consciousness, generalized body ache, anorexia, and occasional vomiting. There was no history of neck rigidity, photophobia, seizure, and covert or overt bleeding. General and systemic examinations were unremarkable. The patient's blood pressure and pulse rate were 114/76 mm Hg and 110-120 per minute respectively. Investigations were done on the third day of fever. His IgM ELISA for dengue was positive; other investigations revealed a platelet count of 26,000/mul, total leukocyte count: 5400/cmm with lymphocytes 46%. Blood electrolytes, blood sugar, lipid profile, and renal function tests were within normal range. Liver function tests were also normal except for aspartate transaminase (258 IU/ml) and alanine transaminase (366 IU/ml). The blood smear was found to be negative for malarial parasite. Prothrombin time was 13 seconds but bleeding time was increased (9 minutes). He was diagnosed as a case of dengue fever with thrombocytopenia. The patient received three units of platelet concentrates transfusion and was kept under observation and received only supportive therapy.
On the third day of dengue fever, the patient exhibited discernable symptoms (mentioned above) of a manic episode. His past, personal, and family history was noncontributory. Mental status examination revealed a young man of average built, wearing bright yellow colored shirt and green trousers with a pink hat with a string of beads round his neck. He appeared authoritative. While talking, it was difficult to interrupt him. He refused to sit despite being requested to do so by the examiner. He continued to move about in the examination room chanting some mantras and in between making claims of possessing special superhuman abilities like ability to engulf the sun, to trap the air, so on and so forth. No amount of explanation could shake him off his grandiose delusions rather it increased his irritability. There was no evidence of any formal thought disorder. Higher mental functions were found to be within normal limits. His abstract thinking was intact on formal assessment. The judgment was found to be impaired with insight of grade 1. His young mania rating scale (YMRS) score was 29. Mini Mental State Examination revealed no cognitive impairment with score of 28/30. Computed tomography scan of the head was found to be normal. He was started on tablet divalproex sodium 1500 mg/day and risperidone 6 mg/day to which he responded successfully within 3 weeks. Subsequent blood investigations conducted on day 18 of admission were within normal limits and he was followed up in the outpatient department of psychiatry for 3 months and did not develop the symptoms of mania.