This unusual case underscores the need for psychiatrists to consider treatable and curable causes of acute behavior changes even when historical data are not easily available. This case presentation invites physicians of mind (and body) to utilize simple and common-sense approaches while evaluating their patients

Brooks, MD, Ellen F.

Ibrahim, MD, Zafar Y.

Name not available

Case Report: Sometimes a Cigar is just a Cigar

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Case Report:Sometimes a Cigar Is Just a CigarZafar Y. Ibrahim , M.D.Ellen F. Brooks, M.D.AbstractTh is unusual case underscores the need JOr psychiat rists to consider treatable and curablecauses if acute behavior changes even when historical data are not easily available. Th is casepresentation in vites physicians ifmind (and body) to utilize simple and common-sense approacheswhile evaluating their patients.CASE REPORTA 40-year-old sing le Caucas ia n man was ad mitt ed to t he hospita l becau se ofrelapse of psychosis a nd suicidal ideation . The patient had stopped tak ing his lithi uma nd hal op eridol several da ys pri or a nd was expe rie ncing a udi tory hall ucina t ions. Hecla ime d th at voices were telling him to throw hims elf in fro nt of a ca r. The pa tien thad a st ressfu l relation ship with his fat he r a nd siste r beca use they had not a llowedhim to stay wit h them . The patien t was un employed a nd homeless.Hi s psychiatric hist ory included multiple ad miss ions for sch izoaffect ive di sorder,polysubst ance a buse (a lcoho l, marijua na, cocaine) , a nd a nt isocia l persona lity disor -der. There was a hist ory of a suicide a tte m pt in 1974 by han gi ng. H is outpa t ientmedi cations included lithium, benzt ropine, and halop eridol. The pat ient was non com-pliant regarding outpa tient medicati ons as evide nced by subtherapeutic serum levels a t thetim e of his admission to th e hospit al. He smoked three packs of cigarett es per day and wascur re ntlyabusing marijuana. Ther e was no histo ry of medical or surgical illness.Mental S tatus ExaminationThe patient was a lert , ori ent ed, and well groom ed. Hi s beh avior was a ppropriat efor the int erview. His mo od wa s depress ed; he disp layed cons t r icte d affec t a nd mi ldag ita t ion. Thought con te n t included su icidal ideation and auditory com mand ha lluci-nations, as mentioned pr evious ly. H e score d 29/30 on th e Mini Mental Sta teEx amination (I) wit h a deficit in delayed recal l. Hi s judgement was not ed to be poor ,as was insight into his di agnosis a nd his social and enviro nme nta l sit uat ion.Za far Y. Ib rahim , M.D. is a PGY -3 resid ent in th e Dep artmen t of Psychi a try at th e Vet eran sAffa irs Medi cal Ce nter and th e Univers ity Hospit als of C leve la nd . Ellcn F. Brooks, M.D. is anAss ista nt Pr ofessor of Psychi atry at Case West ern Rese rve Un iversi ty.2SO MET IMES A CIGAR IS J UST A CIGARMedical Examination3Physical examina t ion a t th e time of admission revealed a well-developed ,Caucasia n man. H e appeare d to be in no physical d istress a nd he denied an y currentme dica l problems. The results of his physical exami nation were within normal limi ts.Lab orat ory findings at the t ime of admission we re unremarkable ex cept for aurine toxi cology screen positive for marijuan a , a whi te blood cell count of 12.3 X109/L, a nd a se rum lithium level of O. l. Becau se th e patien t was afebri le and did notcompla in of a ny physical problems, his mildly increased white blood cell count wasatt r ibu ted to st ress.ImpressionThe admitting diagnoses were schizoaffect ive disorder in acute exacerbation andca nna bis abuse . H e was assessed to be a moderate suicide risk as an outpatientbecause of his past suicide a ttempt in 1974, presence of auditory ha llucinations , andpoor j udgement.Clinical CourseDuring his hospital iza tion, the patient received lorazepam , haloperidol , lithiu m,be nz t ro pine mesyla te, a nd diphenhydramine hydrochloride. This treatment regim enres ulte d in a decrease in his psych osis a nd ag itat ion. By the sixth hospital day thepa t ien t's aud itory hallucin ations had significa n tly decreased. On day 12 of hishos pital stay, he complaine d of righ t-s ided headache and was given acetaminophenand ibuprofen; these were ineffecti ve in controlling his pain.T he patient was observed, on day 13, to be standing in a ha llway hold ing histh roat as if t ryin g to cho ke himself. Wh en as ked if some thing was wrong, he abrupt lystopped th is gagging behavior and ca lm ly req uested " syrup ofIpecac ," saying th at hewan ted to vomi t. Wh en as ked why he wa nted to vom it, he deni ed th at an ything waswro ng, and rep eated his request for syru p of Ip ecac. T he pa t ien t was to ld that hewould not be given suc h medi cin e if he had no medi cal reason for it. He la ter claimedhe could not hear, alt ho ugh he was a ble to com m unica te wit h staff, and that his teethhu rt. The on-ca ll resid ent eva luated th e patient , noted that his ea r was tender duringt he exam, a nd be lieved th at a cerumen plu g was the ca use of the hearing difficulty.On fur the r qu esti oning as to a possibl e ca use for th e ear tenderness, the patientrecalled using a nail to clean his ea rs. He state d , " I think t he nail got broken becau se Isaw only hal f th e nai l in my hand, so maybe the ot he r hal f is st ill in my ea r. " Thepa tien t denied having a ny discharge from his righ t ear.The patient was taken to th e radi ology dep artment whe re plai n roe ntgenogramsof his skull (Figure) revealed a round, bu tt on-sized foreign body deep in his exte rn alau d itory ca nal. The pa tient was given a local a nest het ic an d the for eign body wasre moved by a n ea r, nose, and throat specialist usin g an operative microscope. Theforeign body proved to be a button-sized alka line battery. At thi s point the patient4 J EFFERSON JOURNAL OF PSYCHIATRYFigure. Posteroanterior roentgenogram of patient's sku ll sh ows alkaline battery deepwithin the r igh t auditory canal.told us , " Now I remember th at before coming to th e hospital I was list en ing to musicusin g an ea rpho ne, and I think that is how this battery got transferred into my ear."Aft er th e battery was removed th e patient 's pain disappeared d uri ng th e next 24to 48 hours. Hi s hearing improved , and his desire to vom it re solved .DISC USSIONThere a re seve ra l s t riking as pects to this case . Fi rst , this odd be havior (chokingonese lf) mi gh t be easily dismissed in a suicidal, psych oti c patient as sim ply manifest a-tion s of th e underlyin g psychiatric di seas e. Second, th is pat ien t did not init iall ycom pla in of pain in his ear, a lt houg h a relatively la rge fore ig n body was lodged deepwithin th e ex te rna l a ud itory ca nal, a nd during removal of this foreign body th epatient expe rience d sig nifica n t pain. Third, th e for eign body was not visible in th ea uditory canal a nd required radiological eva lua t ion for det ecti on. Fourt h, th e pat ientSOMETIMES A CIGAR IS J UST A CIGAR 5seemed unable or unwilling to tell th e physicians that th ere was so met hin g in his ea r,although he had almost cer ta inly placed it th ere himself. These de ta ils made th ecorrect diagnosis of a foreign bod y in th e ea r potentiall y very easy to miss.Acutely psychotic patients may be unable to verba lize th e presen ce of ph ysicalproblems du e to limitations in comm unica t ion ca use d by th eir psych osis . In this case ,th e battery was lodged very deep within th e auditory ca na l a nd could hav e beenirritating nerves responsible for elicit ing a gagging se nsat ion. Alt ern a t ively, thepatient could have been trying to expel something he kn ew was th ere but was not abl eto consc ious ly or verbally acknowled ge (he insi st ed on tryin g to vomi t it ou t ins tead ofrequesting manual removal).Psychotic patients have been kn own to self-mutilate or s tuff th eir body cav ities.Patients give varied expla na t ions for such acts- re ligious reason s (2), a ud itorycom ma nd hallucin ations , and to assuage feeling of em ptiness or to fill a psych ic void(3). In 1989 , Favazza e t a l conclude d " devia n t se lf-m ut ila t ion is best t ho ught of as apurposeful, if morbid, act of self-help" (2). Interestingly, alt ho ug h th ere are severalpsychosis-r elated ca uses for ear stuffing, in some cases, patients may ben efit from th erestriction of a ud itory input. The use of ea rplugs has been associated wit h a reducti onin a uditory hallucin ations in a subgroup of patients with chro nic psych oses (4).A routine ph ysical exa mina t ion and laboratory an alysis, as was init ially done inthis case, may not un cover th e real ca use of th e physical problems. Alt hough th emildly eleva te d white blood ce ll coun t was originally thou gh t to be ca used by stress , inretrospect it may have been du e to a n inflammatory process in this pat ient 's rightea r. In this case, we were able to elicit ex t re me tenderness on manipulat ion of th epatien t 's rig h t ear, leading us to suspect a n organic problem even when th ere was novisibl e abnormality. Fortunately th e patient was immedi at ely reexa mined; th elod ging of an alk aline battery in th e exte rnal a uditory ca na l cons t itu tes a trueeme rge ncy, as leaking a lka li ca n ca use liqu efacti on necr osis of skin, bo ne, and th etympanic membran e, as well as facial nerve palsy (5).The importance of obtaining a roentgenogram to evalua te this pa t ie nt 's com-plaint is obviou s, and se rves as a vivid reminder th at , to paraphrase a remarkcom mo nly a tt ribu te d to Freud, so me t imes a cigar is just a cigar, and even a ppa re ntlydelusional com pla in ts may need further eva lua t ion.REFER ENC ES1. Folst ein MF, Folst ein SE , McHugh PR: Mini-Mental Sta te : a practical me thod for grad ingthe cog nit ive sta te of patients for th e clinician .] Psychia t r Res 1975; 12: 189-1 982. Favazza AR . Wh y pat ient s mu t ila te th emse lves. Hosp Community Psychia t ry 1989; 40:137-1453. Kroll T C, Wi se T N. C ite d by: Weiser M, Levy A, Ne u man M, et a l: Ea r st uffing: An unusualfor m of se lf-m u t ilat ion. ] Nerv Ment Dis 1993; 181:587- 5884. Birchwood M: Co ntrol of au d itory hall ucinat ions th ro ugh occlusion of mon aural a udi to ryinput. Br] Psychi atry 1986; 149:104-1 075. McRae M , Pr em achandra D] , Ga t land ] : Button batt er ies in th e ear, nose, and ce rvica lesuphagus: A d estructi ve foreign body. ] Otola ryngol 1989; 16(6) :317

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Case Report: Sometimes a Cigar is just a Cigar

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