A twenty-one-year-old primigravida with an uneventful antenatal period presented two weeks postpartum with new onset of behavioral abnormalities and irrelevant talking since prior five to seven days. She underwent hospital-based normal delivery at full term. She was noticed by her family to behave abnormally in the form of crying spells, anger outbursts, irrelevant talking, ideas of persecution, wandering behavior, and disturbed sleep. She was observed being detached and disinterested in the baby, and having unexplained fear. She did not have fever, headache, vomiting, seizures, or trauma. In her past, she never had similar episodes and her family denied any depressive features or use of any long-term medications prior to onset of the symptoms. She was admitted at a local hospital where she progressively lapsed in to a state of near akinetic mutism.
On examination, her vital parameters were normal. She looked apathetic with no spontaneous limb movements or vocalization. She seemed to be muttering to herself with occasional crying spells and did not obey any commands. In view of negativism, orientation to time, place, or person could not be assessed. Tone in extremities and deep tendon reflexes were normal. There were no signs of waxy flexibility or meningeal irritation. Remaining neurological and systemic examination, including fundus, was unremarkable.
Magnetic resonance imaging (MRI) of brain at admission showed isolated diffusion restriction and low apparent diffusion coefficient (ADC) values in splenium of corpus callosum, extending into the body of corpus callosum. There was mild edema in T2 and Fluid Attenuated Inversion Recovery (FLAIR) sequences. The lesion did not enhance after gadolinium administration [Figure 1]. Specifically, no lesions were observed in other cortical or subcortical white matter and posterior circulation territory. Cerebral angiogram and venogram were normal. Her hemogram, metabolic panel, erythrocyte sedimentation rate, thyroid profile, autoimmune panel, urine routine, and chest x-ray were normal. Serum vitamin B12 level was 218 pg/ml. Blood and urine cultures did not grow any organisms. She tested negative for Salmonella, Tuberculosis, Dengue, HIV, and respiratory infections. Her history, clinical examination, and investigations did not show any evidence of infective or metabolic diseases. Electroencephalography was negative for any epileptiform discharges or slowing of background activity. Cerebrospinal fluid (CSF) analysis showed normal proteins, sugar, and cell count. CSF Polymerase Chain Reaction (PCR) for tuberculosis and herpes were negative. Visual evoked potential (VEP) and Brainstem Auditory Evoked Potential (BAER) were within normal limits.
She was initially managed empirically with Ceftraixone and Acyclovir. With normal CSF picture, these medications were stopped and psychiatry consultation was sought. She was diagnosed to have postpartum psychosis and was started on Lorazepam, Escitalopram, and Olanzepine, along with behavioral counseling. Following these medications, progressive improvement was noted in her clinical status. Her symptoms of crying spells, persecution, and wandering recovered. She became oriented with normal vocalization and sleep. She was discharged after ten days of hospital stay and is awaited for follow up.