UH Med Now

Ilana Buffenstein, MD candidate 2022, has recently been published at psychiatrist.com/pcc: The Primary Care Companion for CNS Disorders. Co authors from JABSOM’s Department of Medicine’s Miki Kiyokawa, MD, and Psychiatry’s William Haning, MD, mentored Buffenstein during her study that produced the article “Severe Hypothyroidism in a Hypomanic Patient with Sepsis.” 

“My case report discusses an unusual psychiatric patient presentation, in which I theorize that a patient’s chronic health conditions affected the presentation of his bipolar disorder,” Buffenstein said. “This patient case was particularly interesting because bipolar mania is a multi-factorial illness. We don’t always know what causes people to enter into a manic state, and in this case, our patient’s sepsis and thyroid dysfunction may have played a role in modulating his mania.” 

Buffenstein, who is applying for obstetrics and gynecology residency for the 2021-2022 match cycle, says she is most intrigued by the intersection of pregnancy and mental health: “Postpartum depression and psychosis are very real and devastating conditions, and in residency, I hope to support and serve pregnant women with mental health disorders, to better optimize both maternal and fetal health.”

This particular case involved a homeless middle-aged man who went to the emergency department with “notable grandiosity, claiming that he wanted to help and befriend everyone,” and was happy to be alive. But he also presented a plethora of issues such as acquired hypothyroidism, bipolar disorder with recurrent documented manic episodes, chronic cellulitis of a leg, and he was septic. Buffenstein writes that the patient reported that he self-tapered off all psychiatric medications over the past two years, with the last taper of a medication three months prior because he said his insurance messed up the prescription.

“He described that his current presentation was very different from his past manic episodes, during which he would spend ‘tons of money on sports cars,’ felt like Superman, and exhibited violent outbursts with frequent police arrests,” wrote Buffenstein. 

According to Buffenstein, the man was admitted for his physical maladies, but adamantly refused psychiatric treatment, over the course of the six days he was an inpatient. After cultures and wound care indicated physical healing, the psychiatric team determined him not to be an acute safety risk and he was discharged with medicine and further outpatient treatment scheduled. 

“He was also given an outpatient psychiatry follow-up appointment, to which he was agreeable,” she wrote. “He was subsequently lost to follow-up.” 

While this may be a cliffhanger for armchair experts, it must be often that such patients keep walking and never return for follow-up treatment. Buffenstein says this case reinforces the importance of screening for thyroid disorders, infections in patients with bipolar illness, and of encouraging medication adherence.

“The case report itself is complete – however, I look forward to collaborating with my colleagues in psychiatry on similar future cases when I am an OB resident,” Buffenstein said. 

Paula Bender, UH Med News