Organic Depression and Terson's Syndrome in Adult Polycystic Kidney Disease: Case Report and Review of Literature
A 50-year-old lady, receiving treatment for hypertension for the past 8 years, was diagnosed as having comorbid organic depression as per ICD-10 diagnostic criteria,[] and was symptomatic for the past 4 months. She was managed with escitalopram (10 mg/day) and mirtazapine (15 mg/day), but was in partial remission. She presented to the psychiatry out-patient services with exacerbation of symptoms of pervasive depression, apathy, insomnia, anorexia, fatigue, reduced social interactions, and frontal headache for the past 4 months, with diminished vision and vomiting for the past 1 week. Episodic frontal headache was followed by unresponsiveness and sudden fall without tonic — clonic limb movements or injuries, lasting for about 10 min with amnesia for the event. She had no history of head trauma, epilepsy, substance (alcohol, nicotine, or drug) abuse, or psychosocial stressors. She had second-degree consanguineous marriage. Family history of late-onset kidney diseases and hypertension was noted in both her parents and ADPKD was diagnosed in both her sons.\nOn admission, the Glasgow Coma Scale[] score was E4V5M6 and Hunt — Hess scale[] was grade-1, with blood pressure of 190/110 mm Hg. Neuromuscular and cardiovascular examination was normal. Mental status examination revealed depressed mood, apathy, negative cognitions, impaired judgment with preserved attention, orientation, memory, and intelligence, with grade-4 insight. Hamilton depression rating[] (HAMD-17 item) score was 16 and the score on the mini-mental status examination[] was 28/30. Ophthalmological evaluation revealed reduced visual acuity in the right eye (1/60) and normal left eye (6/6), bilaterally normal anterior segments, normal pupils (bilaterally 3 mm, round, regular, and reacting to both direct and consensual light reflexes), and normal intraocular pressures. Fundoscopy showed boat-shaped subhyaloid hemorrhage involving the posterior pole extending below the inferior arcade, with multiple hemorrhages seen around the normal optic disc in the right eye [] and normal left fundus [], with evidence of bilateral grade-1 hypertensive retinopathy []. Hematological and biochemical investigations revealed moderate normocytic and normochromic anemia (hemoglobin 8.7 g/dL), mild leukocytosis (12,240/mm3), raised serum creatinine (2.5 mg/dL) with normal blood urea (42 mg/dL), serum electrolytes, blood glucose, lipid, liver, and thyroid profiles. Ultrasonography (USG) of abdomen showed bilateral renal ill-defined multiple (>6) cysts and calculi []. Echocardiography revealed mitral valve prolapse along with trivial mitral and aortic regurgitation. Electrocardiograph and carotid Doppler studies were normal. Electroencephalography showed right frontal polyspikes and sharp waves with preserved alpha background activity suggestive of epileptogenic foci. Cranial magnetic resonance imaging (MRI) revealed minimal SAH in the anterior inter-hemispheric fissure and adjacent cortical sulci with edema in adjacent frontal lobes, and hyper-acute SDH in bilateral fronto-temporo-parietal regions along the cerebral convexities (5 mm), with no mass effect or midline shift [], confirming the diagnosis of TS. Cerebral angiography showed small bi-lobed aneurysm (6 × 6 × 4 mm) arising from the ACoA with the neck of aneurysm measuring 1.5 mm in medio-lateral direction [].\nManagement included anti-hypertensives, antiepileptics, zolpidem, and hematonics. Antidepressants were withheld for the risk of re-bleed. Neodymium: YAG (Nd: YAG) laser posterior hyaloidotomy was performed by transcorneal route using frequency doubled Nd: YAG laser 532 nm (Zeiss-Visulas YAG laser 532 nm; laser setting: 9 spots, 100 msec duration, 50 μm spot size for penetration burn, 130 mW power) delivered via a slit lamp using Goldmann lens.[] The aiming beam was focused on the sloping edge of the most dependent portion of posterior hyaloid membrane at the inferior edge of subhyaloid hemorrhage to facilitate gravity-induced drainage. Blood flowed from hyaloidotomy opening and dispersed into inferior vitreous. Patient was advised for head-end elevation, and later discharged with anti-hypertensives, antiepileptics, and zolpidem. A week later, near-complete resolution of subhyaloid hemorrhage [] and ICH, with mild ventriculomegaly [] was noted. A month later, aneurysm clipping was successfully done by the neurosurgeon in liaison with a nephrologist. A month later, patient was asymptomatic with HAMD-17[] score of 3, and was regularly followed up for a year following neurosurgical intervention. She remained euthymic without any active psychiatric interventions and was managed with antihypertensives and antiepileptics alone. This sequential presentation with full remission of symptoms following neurosurgical interventions led to the diagnosis of “possible” organic depression due to intracranial ACoA aneurysm as per ICD-10 diagnostic criteria.[]