CASE REPORT

Schizoaffective disorder associated with recent Toxoplasma gondii infection

 Tulburare schizoafectivă asociată cu infecţie recentă cu Toxoplasma gondii

First published: 30 septembrie 2024

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Psih.78.3.2024.10092

Abstract

The specialized literature suggests that the infection with Toxoplasma gondii may be associated with an increased risk of developing psychiatric disorders, particularly those within the schizophrenia spectrum. This article presents a complex case of schizoaffective disorder associated with a recent Toxoplasma gondii infection. Although the infection did not present with obvious clinical symptoms, it was discovered during the seroconversion period, suggesting a recent infectious episode that may be relevant in the context of psychosis. In this infectious background, the biological link raises the possibility of a triggering or exacerbating factor for the current psychotic symptomatology.
 

Keywords
schizoaffective disorder, Toxoplasma gondii, seroconversion period, antipsychotic treatment

Rezumat

Literatura de specialitate sugerează că infecţia cu Toxoplasma gondii poate fi asociată cu un risc crescut de dezvoltare a tulburărilor psihiatrice, în special tulburări din spectrul schizofreniei. Acest articol prezintă un caz complex de tulburare schizoafectivă, asociată cu o infecţie recentă cu Toxoplasma gondii. Infecţia, deşi nu a prezentat simptome clinice evidente, a fost descoperită în perioada de seroconversie, sugerând un episod infecţios recent care poate fi relevant în cadrul psihozei. În acest context infecţios, legătura biologică aduce în discuţie un posibil factor declanşator sau de exacerbare a simptomatologiei psihotice actuale.
 

Schizoaffective disorder is a mental condition that combines symptoms of schizophrenia with mood disorder symptoms, such as depression or mania. Individuals with this disorder may experience hallucinations, delusions and thought disturbances, along with symptoms of depression or mania. There are three main types of schizoaffective disorder(1):

  • Depressive type – characterized by episodes of major depression.
  • Bipolar type – including episodes of mania or hypomania.
  • Mixed type – a combination of depressive and manic symptoms within a single episode.

Case study

A 36-year-old patient, P.B., presented at the Timişoara Psychiatric Clinic, Romania, with a first hospitalization in Austria two days prior to admission, diagnosed with acute psychotic disorder. He was brought in by his family, displaying a psychopathological profile dominated by delusional ideas of persecution, surveillance, being followed, being poisoned, sensitive-relational ideas, delusion-driven behavior, and marked anxiety.

Family history: insignificant.

Personal history: insignificant.

Living and working conditions: the patient was not married, living in the rural environment, reporting adequate living conditions. He worked as a truck driver, with a heavy workload and shift work, including night shifts. The patient was an Orthodox Christian and a practicing one.

Substance use: he denied substance use, for religious reasons.

Evaluations

Cardiology consultation: the ECG showed sinus rhythm, without acute ischemic changes. The echocardiogram results were within normal limits. The patient presented with atypical parietal chest pain. Blood pressure (BP) = 150/80 mmHg, heart rate (HR) = 90 bpm. Diagnosis: sinus tachycardia. Atypical chest pain. Recommendation: BP and HR monitoring. Treatment: Corlentor® 5 mg, 1-0-1.

Infectious diseases consultation: the patient was asymptomatic for Toxoplasma gondii infection (IgM<IgG). Diagnosis: chronic T. gondii infection during the seroconversion period. Recommendation: monitoring and retesting in one month. No treatment required.

Mental examination

Appearance: the patient presented with good personal hygiene and a relatively tidy appearance, being oriented.

Facial and gestural expressiveness: in line with the affective experiences, but within normal limits.

Attention: hypoprosexia (reduced ability) for concentration and persistence.

Memory: hypomnesia (impaired memory) for fixation and recall.

Perception: imperative auditory pseudo-hallucinations, elementary visual hallucinations, kinesthetic hallucinations.

Thinking: delusional ideas of poisoning, being followed, of harm, mystical ideas, transparency-influence phenomena (behavioral control), prevalent ideas of possession.

Affectivity: secondary anxiety due to psychotic experiences, mildly depressive mood alternating with dysphoric mood, irritability, low tolerance to frustration.

Behavior: increased vital energy, accentuation of hedonistic behaviors, delusion-driven behavior.

Appetite: decreased.

Circadian rhythm: mixed insomnia.

Medical history

The patient described a first psychotic episode approximately eight years ago (delusional ideas of poisoning, bewitching, marked anxiety). According to the patient and the heteroanamnesis, the patient sought many specialist consultations, being suspected of pheochromocytoma, but never came into contact with psychiatric services. The remission was spontaneous but slow (one year). Following this episode, the patient developed a religious preoccupation, which he claimed it was beneficial in alleviating symptoms. The current psychopathological profile developed slowly over approximately one and a half months. Three days before admission, the patient had been hospitalized in Austria with the diagnosis of acute polymorphic psychotic disorder, being discharged after one day, with the recommendation to seek hospitalization in Romania.

Psychometric scales

  • PANSS-R T=98 (P=31, N=18, G=49), evolving to T=46 (P=13, N=8, G=25).
  • YMRS score 24 (moderate mania), evolving to 9 (mild mania).
  • HAM-D score 13 (mild depression), evolving to 3 (subclinical).
  • HAM-A score 29 (severe anxiety), evolving to 3 (subclinical).
  • The abstract thinking test and the verbal associative experiment revealed thought disturbances with a tendency toward hyperconcrete thinking.
  • SCL-90 revealed slightly elevated indices for paranoid ideation, sensitivity, and somatization.
  • The Birchwood Scale indicated good insight for the need for treatment, reduced insight for symptoms, and absent insight of the illness.
  • The Draw-a-family Picture Test and the self-portrait test revealed bizarre notes, with a tendency toward aggression and obsessiveness.

Psychodiagnostic examination

The patient was a person with emotional lability and impulsive tendencies, perseveration with adhesiveness, and a censored sensitivity need for recognition. There were signs of possible anxious-depressive mood. Isolated psychotic signs, in the process of receding, without major decompensation at the time of evaluation. No clear signs of organic impairment were present at the time of evaluation.

Neurological and imaging examination

Objective neurological exam revealed no signs of focal irritation.

The cerebral MRI revealed no abnormal signal or structural changes, with symmetrical ventricles along the midline, of normal size. Normal appearance of extracerebral fluid spaces. The cerebral vascular axis with normal flow. Cranio-spinal junction of normal appearance. Orbits, paranasal sinuses, and temporal bones showed normal MRI appearance. Slight thickening of the mucosa in the maxillary sinuses bilaterally, predominantly on the right, and in the frontal sinuses bilaterally, along with the ethmoid cells’ walls. Cervical spine revealed slight rectification. Small posterior osteophytes at C2, C3.

EEG: irritative pattern, with pathological graphoelements (spikes), especially during the activation of the tracing.

Laboratory tests

  • Cortisol and thyroid hormones were normal.
  • Hypercholesterolemia.
  • Toxicology: negative for psychoactive substances, negative for mercury (tested at the patient’s request, as mercury was the primary substance associated with the poisoning delusion).
  • ACTH and plasma-free metanephrines were normal.
  • Positive Toxoplasma gondii antibodies (IgG, IgM).
  • Anti-NMDA receptor antibodies were normal.

Positive diagnosis

Based on the patient’s history, the clinical examination, mental health evaluation, psychodiagnostic examination, psychometric scales and medical history, a diagnosis of schizoaffective disorder, current mixed episode, was established. The current episode met the diagnostic criteria for schizophrenia (paranoid delusional ideas of persecution, poisoning, mysticism, xenopathic influence), as well as for a mixed affective episode (depressive mood alternating with dysphoric mood, irritability, low frustration tolerance, increased vital energy, accentuation of hedonistic behaviors, ruminations on existential themes and illness), with a duration exceeding one month.

Differential diagnosis

Organic delusional disorder of schizophrenia type (F06.2): the MRI imaging and other paraclinical tests did not indicate any cerebral dysfunction or other organic diseases that could lead to an organic delusional disorder.

Mental and behavioral disorders due to psychoactive substance use. Psychotic disorder (F1X.5): the history, clinical examination and the toxicology tests ruled out this suspicion.

Schizophrenia: the diagnosis was ruled out by the presence of marked affective symptoms.

Delusional disorders (F22): the delusional symptomatology was not a prominent component present for an extended period.

Brief psychotic disorder (F23): the onset had occurred more than a month before. Additionally, the previous psychotic episode reportedly lasted one year.

Bipolar affective disorder, mixed episode: the diagnosis was ruled out by the presence of first-rank symptoms specific to schizophrenia spectrum disorders (transparency-influence phenomena such as behavioral control).

Pheochromocytoma: the laboratory tests were not suggestive of pheochromocytoma.

Anti-NMDA receptor encephalitis: testing for anti-NMDA receptor antibodies was negative.

Current treatment

During hospitalization, the patient followed a medication treatment with:

  • Haloperidol solution, 40-40-60 drops, gradually reduced and removed from the therapeutic regimen.
  • Parnido® 3 mg, 4-0-0.
  • Romparkin® 2 mg, 1-1-1, reduced to 0-0-1.
  • Rivotril® 2 mg, ½-½-1, gradually reduced to 0-0-¼.
  • Levomepromazine 25 mg, ½-½-1, reduced to 0-0-1.
  • Imovane® 7.5 mg, 0-0-1, later removed from the therapeutic regimen.
  • Orfiril® 1000 mg, 0-0-1.
  • Trittico® 150 mg, 0-0-⅔.
  • Corlentor® 5 mg, 1-0-1.

 

Recommended treatment at discharge

  • Xeplion® 150 mg injection, monthly.
  • Levomepromazine 25 mg, 0-0-1.
  • Orfiril® 1000 mg, 0-0-1.
  • Trittico® 150 mg, 0-0-⅔.
  • The personal medication for the associated somatic conditions.

The treatment will continue on an outpatient basis, with periodic reevaluation, which involves simplifying and readjusting the treatment. The injectable form was chosen for its simplicity and the increased therapeutic adherence.

Psychosocial interventions

Psychoeducation provided during hospitalization. Both the patient and his relatives were informed about the symptoms, treatment (including side effects), and prognosis.

Supportive therapy: the patient must be helped to cope with stressful situations to avoid possible psychotic decompensation.

Cognitive-behavioral therapy (CBT) can help the patient understand his emotions and thoughts, and gain better control over his symptoms.

Family therapy: although the family situation is good, the mother-son dynamic involves certain elements of intrusiveness and hyperprotection that could benefit from family therapy.

Possible complications

Medication: hyperprolactinemia, sedation, secondary parkinsonism, anticholinergic effects, dry mouth, constipation, QT interval prolongation, hypotension, nausea, dizziness.

Psychiatric: relapses due to future psychotic, manic, or depressive episodes, chronicity.

Social: decreased quality of life, social dysfunction.

Case particularities

An important particularity of this case is the presence of a previous psychotic episode with spontaneous but very slow remission (according to both the patient and external accounts).

Another particularity is the recent infection with Toxoplasma gondii, a parasite associated with an increased risk of developing or worsening schizophrenia spectrum disorders(2).

Evolution

Without treatment, the illness has a high chance of multiple relapses and chronicization. Relapses can involve psychotic, depressive, manic, or mixed episodes. The risk of chronicization and social dysfunction is also high in untreated schizoaffective disorder.

With treatment, the chance of multiple relapses is relatively low, and the patient may maintain full social functionality.

Positive prognostic factors include: the presence of a social support network, the presence of affective components, the absence of genetic predisposition, and relatively good premorbid functioning.

The negative prognostic factors include: male gender, a history of working night shifts, and onset before the age of 30 years old.

Discussion

The case of our patient represents a complex example of schizoaffective disorder associated with a recent infection with Toxoplasma gondii. Although this infection did not present with obvious clinical symptoms, it was discovered during the seroconversion period, suggesting a recent infection that may be relevant in the context of psychosis(3). The literature suggests that Toxoplasma gondii infection is associated with an increased risk of developing psychiatric disorders, particularly within the schizophrenia spectrum. This biological link raises the possibility of a triggering or exacerbating factor for the current symptomatology.

On the other hand, schizoaffective disorder is difficult to diagnose, due to the overlap of psychotic and affective symptoms. The patient exhibited both delusional ideas of persecution and poisoning, as well as a mood that fluctuated between depression and mania, suggesting a mixed episode. The differential diagnosis ruled out other potential causes, such as organic disorders, pure schizophrenia, substance-induced psychotic disorders, or simple affective disorders, due to the presence of first-rank symptoms specific to schizophrenia and altered affectivity.

Another significant aspect of the case is the relatively slow and insidious onset of psychotic symptoms, with a similar episode occurring eight years ago, which spontaneously remitted. This suggests a latent psychotic vulnerability that, although remitting in the short term, carries a high risk of relapse without proper treatment. Additionally, his history of night-shift work, a known risk factor for mood and psychotic disorders, may contribute to the worsening of current symptoms.

During hospitalization, antipsychotic and mood-stabilizing treatment led to a clear improvement in both psychotic and affective symptoms, as reflected in the decreased scores on the PANSS-R, YMRS and HAM‑D scales. However, the pharmacological intervention was gradually adjusted to minimize the side effects, which include risks such as excessive sedation, secondary parkinsonism, and QT interval prolongation. The choice of an injectable formulation (Xeplion®) at discharge aims at improving the therapeutic compliance, a critical aspect in preventing relapses.

Conclusions

This case highlights the complexity of diagnosing and managing schizoaffective disorder, especially in the context of biological risk factors, such as a recent infection with Toxoplasma gondii. Although the exact etiology of schizoaffective disorder remains unknown, the combination of environmental factors (night-shift work and a stressful lifestyle) and biological factors (infection with Toxoplasma gondii) may contribute to the exacerbation of psychotic and affective symptoms.

Early diagnosis and appropriate treatment are essential for preventing relapses and the chronicization of the disease. In the case of our patient, the evolution under treatment has been favorable, and the strong social support network, combined with the affective component of the disorder, represents a positive prognostic factor. However, the risk of psychotic and affective relapses remains present, underscoring the need for careful long-term management of the illness, both through pharmacological and psychosocial interventions.

Potential complications include risks associated with antipsychotic and mood-stabilizing medications, as well as social dysfunction and psychotic relapses in the absence of close monitoring. Additionally, similar cases could benefit from further studies investigating the link between Toxoplasma gondii infection and psychiatric disorders, considering the impact of this infection on mental health. 

 

 

Autori pentru corespondenţă: Virgil-Radu Enătesccu E-mail: renatescu@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.

Bibliografie

  1. Malaspina D, Owen MJ, Heckers S, Tandon R, Trump D, Schultz S, Barch DM, Gaebel W, Gur R, Tsuang M, Van Os J, Carpenter W. Schizoaffective disorder in the DSM-5. Schizophrenia Research. 2013;150(1):21–5.

  2. Torrey EF, Yolken RH. Toxoplasma gondii and schizophrenia. Emerg Infect Dis. 2003;9(11):1375-1380. 

  3. Contopoulos-Ioannidis DG, Gianniki M, Ai-Nhi Truong A, Montoya JG. Toxoplasmosis and Schizophrenia: A Systematic Review and Meta-Analysis of Prevalence and Associations and Future Directions. Psychiatr Res Clin Pract. 2022;4(2):48-60.

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