Mr J was an 18-year-old academically gifted South American student who was visiting Italy as a tourist. He had normal neuropsychological development during infancy. He was travelling around Europe during his holidays to celebrate the end of high school. He was an easy-going person, having had many relationships but without a significant long-term partner. He had several hobbies (football, technologies, cars) and planned to start his university studies in international politics. He had not experienced any previous psychopathological problems. He did not drink alcohol or caffeine, and did not use any illicit or recreational drugs. His great-grandmother had suffered from schizophrenia.
The patient was admitted to the psychiatric ward of Policlinico Umberto I Hospital, Sapienza University of Rome, appearing to be deeply distressed, dysphoric, and confused, with disorganized speech and thoughts. He presented with persecutory and transformation delusions focused on the idea that every person was a robot with a human body. He had disorganized auditory hallucinations, hearing voices of relatives (mother, father, cousins) telling him to escape from the hospital because there were robots there who wanted to kill him. He did not recognize his cousin (thinking that the cousin was a robot with the body and face of his cousin). A toxicology screen was negative for psychoactive substances.
Computed tomography of the head without contrast did not show any hemorrhagic intraparenchymal or extra-parenchymal lesions or alterations in parenchymal density, either over and under the cerebellar tentorium, and showed normal flow in the ventricular system and cerebral spinal fluid spaces. Blood laboratory investigations were normal, with the exception of white blood cells at 11,650 per muL and neutrophils at 7950 per muL.
On admission, the patient was started on clonazepam 5 mg/day to treat his agitation, risperidone 4 mg/day to treat his psychotic symptoms, and valproate 750 mg/day to treat his dysphoric mood.
On day 3, the patient presented again with fever (38.5 C) and a worsening of his delusional symptoms. His hallucinations had worsened in intensity and frequency. He was distressed, presenting with psychomotor agitation and disorganized behavior, and tried to escape from the ward. Blood tests were again normal, with the exception of white blood cells at 16,790 per muL, neutrophils at 14,440 per muL (86%), and lymphocytes of 7.4%. Microscopic examination of the urinary sediment showed many white blood cells, red blood cells, and bacteria. Urine culture was positive for Proteus mirabilis (>100,000 colony-forming units) and Enterococcus spp (<1000 colony-forming units). Treatment with ciprofoxacin was started at 1000 mg/day. The fever disappeared on day 7, and his psychopathological condition improved. Laboratory blood investigations also improved, with a normal white cell count of 6.330 per muL, neutrophils at 3680 per muL (58.2%) and lymphocytes at 25.4%. By day 8, the delusional and hallucination symptoms had disappeared, the patient was cooperative and well orientated in time and space, and he presented with euthymic mood and normal psychomotor skills. He remembered the hallucinations and delusions as if they had been a dream he had had whilst awake, with qualitative alteration of consciousness. On the same day, because of full remission of symptoms, the patient was discharged from hospital and returned to Brazil accompanied by relatives.