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Psychiatric Manifestation of SSPE

SIR: Subacute sclerosing panencephalitis (SSPE) is a slowly progressive disorder that is typically seen in children and adolescents and has an invariably fatal outcome.¹ Subacute sclerosing panencephalitis (SSPE) has been reported from all parts of the world, but in the West it is considered a rare disease with fewer than 10 cases per year reported in the United States.² Few reports exist of SSPE initially presenting with psychiatric symptoms. We would like to report a child who initially presented to a psychiatry clinic and was later diagnosed with SSPE.

Case Report
A 13-year-old boy with no family history of any psychiatric or neurological illness presented to the neurology outpatient clinic with difficulty in walking. The boy was apparently well about 2 months prior when the parents noticed that the child had become unusually quiet and withdrawn. He began to show less interest in his studies and refused to meet his friends, confining himself to his house most of the day. The usual cheerfulness and naughtiness of the child had disappeared and he showed little inclination for talking to his parents and siblings. On a few occasions his parents found him crying without any particular reason. The patient also started having difficulty in memorizing his schoolwork and finishing his homework began to take longer. A month later the patient would laugh without any particular reason and would start crying when he was questioned. These rapid changes of mood made the parents seek a psychiatric consultation and he was diagnosed with having major depression and was prescribed fluoxetine, 20mg/day, by the psychiatrist. The boy developed difficulty in walking and needed support to walk a week later. The parents noticed sudden jerks of the upper limbs and sought a neurology consultation. The child had not received a mumps, measles, and rumps vaccination and had measles at the age of 5. The physical examination was normal with myoclonic jerks in the upper limbs. A mental state examination revealed labile affect, with no delusions or hallucinations. Initial computed tomography (CT) scan and magnetic resonance imaging scan did not reveal any abnormality. The EEG showed bilaterally symmetrical periodic complexes. The CSF immunological study tested positive for IgG measles antibody in high titers. A diagnosis of SSPE was made and the parents were counseled about the illness and the prognosis. The child’s condition rapidly deteriorated and he was completely bedridden.

Comment
SSPE is a unique slow viral disease in which the measles virus has been identified as the pathogen. The usual age of onset is between 5 and 12 years.¹ Psychiatric manifestations of SSPE that have been reported include schizophrenia with delusions and hallucinations and nonspecific psychosis.^3,4 The emotional lability and depressive symptoms in the initial phase of the illness is interesting. Psychiatrists should be aware of the varied presentations of SSPE and should include it in the differential diagnosis of a young child presenting with cognitive decline and depressive symptoms.

REFERENCES

1. Garg RK: Subacute sclerosing panencephalitis. Postgrad Med J 2002; 78:63–70[Abstract/Free Full Text]
2. Jabbour JT, Duenas DA, Sever JL, et al: Epidemiology of subacute sclerosing panencephalitis (SSPE): report of the SSPE registry. JAMA 1972; 220:959–962[Abstract/Free Full Text]
3. Forrest G, Stores G: Subacute sclerosing panencephalitis presenting with psychosis and possible sexual abuse. Eur Child Adolesc Psychiatry 1996; 5:110–113[CrossRef][Medline]
4. Duncalf CM, Kent JN, Harbord M, et al: Subacute sclerosing panencephalitis presenting as schizophreniform psychosis. Br J Psychiatry 1989; 155:557–559[Abstract/Free Full Text]

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