Atypical presentation of first-episode psychosis: pedal edema in a patient with autism

Parinda Parikh; Aatish Dutta Bhatta; Alisha Arul Alphonse; Jeremy Kays; Shaurya Kumar Singh; Himani J. Suthar; Arnesh Shukla; Parthiv Chunilal Pansuriya; Mahiya Buddhavarapu; Arushi Kaushik Chandra; Zoe Gellert; Mina Oza

doi:10.18203/2394-6040.ijcmph20253281

Authors

Parinda Parikh Department of Psychiatry, Weill Cornell Medical School, White Plains, New York, USA
Aatish Dutta Bhatta KIST Medical College and Teaching Hospital, Lalitpur, Nepal
Alisha Arul Alphonse St. George’s University, Grenada, West Indies
Jeremy Kays Windsor University School of Medicine, St.Kitts, West Indies
Shaurya Kumar Singh Pravara Institute of Medical Sciences, Loni, Maharashtra, India
Himani J. Suthar GMERS Medical College and Civil Hospital, Gandhinagar, India
Arnesh Shukla St. Martinus University, Willemstad, Curaçao
Parthiv Chunilal Pansuriya Government Medical College, Surat, India
Mahiya Buddhavarapu University of Pittsburgh, Pennsylvania
Arushi Kaushik Chandra New York University, New York, USA
Zoe Gellert Tulane University, New Orleans, LA, USA
Mina Oza 2ND ARC Associates, White Plains, NY, USA

DOI:

https://doi.org/10.18203/2394-6040.ijcmph20253281

Keywords:

First episode psychosis, Autism spectrum disorder, Catatonia

Abstract

First episode psychosis (FEP) in adolescents with autism spectrum disorder (ASD) presents unique diagnostic and management challenges due to overlapping symptomatology. Physical findings such as pedal edema are uncommon in early psychosis and warrant careful evaluation, particularly prior to initiating antipsychotic treatment. We report a case of a 16-year-old male with ASD who presented with FEP characterized by catatonia, behavioral rigidity, reduced sleep, and social withdrawal. On examination, he exhibited bilateral pitting pedal edema without evidence of systemic or pharmacologic causes. Collateral history revealed prolonged standing behavior due to motor immobility (catatonia) and behavioral abnormalities. Laboratory and imaging investigations were unremarkable. The edema was attributed to dependent fluid accumulation secondary to catatonic posturing. The patient was initiated on long-acting injectable aripiprazole and supportive measures, including compression therapy and hydration, with close monitoring. This case highlights the importance of distinguishing behavioral and physical manifestations of psychosis from baseline ASD traits and other medical conditions. Pedal edema occurring before antipsychotic treatment is uncommon and warrants a thorough evaluation to prevent inadvertently attributing it to medication side effects. Catatonia-related posturing may be an underrecognized contributor to dependent edema in this population. This case highlights the challenges of diagnosing psychosis in autism, where symptoms may overlap with baseline traits. Catatonia presenting as prolonged standing might result in pedal edema. Comprehensive history and multidisciplinary assessment enables accurate diagnosis and treatment, emphasizing the need for careful monitoring in this population.

Metrics

Metrics Loading ...

References

Kiyono T, Morita M, Morishima R, Fujikawa S, Yamasaki S, Nishida A, et al. The Prevalence of Psychotic Experiences in Autism Spectrum Disorder and Autistic Traits: A Systematic Review and Meta-analysis, Schizophrenia Bulletin Open. 2020;1(1):46. DOI: https://doi.org/10.1093/schizbullopen/sgaa046

O'Donoghue B, Collett H, Boyd S, Zhou Y, Castagnini E, Brown E, et al. The incidence and admission rate for first-episode psychosis in young people before and during the COVID-19 pandemic in Melbourne, Australia. The Australian and New Zealand Journal of Psychiatry. 2022;56(7):811–7. DOI: https://doi.org/10.1177/00048674211053578

Driver DI, Gogtay N, Rapoport JL. Childhood onset schizophrenia and early onset schizophrenia spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2013;22(3):539-55. DOI: https://doi.org/10.1016/j.chc.2013.04.001

Guerrera S, Pontillo M, Chieppa F, Passarini S, Di Vincenzo C, Casula L, et al. Autism Spectrum Disorder and early psychosis: a narrative review from a neurodevelopmental perspective. Child Psychiatry Hum Dev. 2022;53(2):213-29.

Larson FV, Wagner AP, Jones PB, Tantam D, Lai MC, Baron-Cohen S, et al. Psychosis in autism: comparison of the features of both conditions in a dually affected cohort. Br J Psychiatry. 2017;211(3):210–5. DOI: https://doi.org/10.1192/bjp.bp.116.187682

Umar MU, Abdullahi AT. Self-limiting Atypical Antipsychotics-induced Edema: Clinical Cases and Systematic Review. Indian Journal of Psychological Medicine. 2016;38(3):182–8. DOI: https://doi.org/10.4103/0253-7176.183089

Ribolsi M, Fiori Nastro F, Pelle M, Medici C, Sacchetto S, Lisi G, et al. Recognizing psychosis in autism spectrum disorder. Front Psychiatry. 2022;13:867561. DOI: https://doi.org/10.3389/fpsyt.2022.768586

Ferrara M, Curtarello EMA, Simonelli G, Yoviene Sykes LA, Fusar-Poli L, Folesani F, et al. First-episode psychosis and autism spectrum disorder: a scoping review and a guide to overcome diagnostic challenges. Int J Ment Health. 2024;53(1):4–35. DOI: https://doi.org/10.1080/00207411.2023.2276872

Brickman AM, Buchsbaum MS, Bloom R, Bokhoven P, Paul-Odouard R, Haznedar MM, et al. Neuropsychological functioning in first-break, never-medicated adolescents with psychosis. J Nerv Ment Dis. 2006;194(12):925–9.

Fish B. Antecedents of an acute schizophrenic break. Arch Gen Psychiatry. 1977;34(11):1297–301. DOI: https://doi.org/10.1001/archpsyc.1977.01770230039002

Keshavan MS, Schooler NR. First-episode studies in schizophrenia: criteria and characterization. Schizophr Bull. 1992;18(3):491–513. DOI: https://doi.org/10.1093/schbul/18.3.491

Sunwoo M, O’Connell J, Brown E, Lin A, Wood SJ, McGorry P, et al. Prevalence and outcomes of young people with concurrent autism spectrum disorder and first episode of psychosis. Schizophr Res. 2020;216:310–5. DOI: https://doi.org/10.1016/j.schres.2019.11.037

Crespi B, Badcock C. Psychosis and autism as diametrical disorders of the social brain. Behav Brain Sci. 2008;31(3):241–61. DOI: https://doi.org/10.1017/S0140525X08004214

Gopalakrishnan V, Parameshwaraiah ST, Malyam V, Sannappa AC, Riyaz S. Peripheral and facial edema associated with olanzapine: A case report. J Pharmacol Pharmacother. 2012;3(1):80–1.

Ku HL, Su TP, Chou YH. Ziprasidone-associated pedal edema in the treatment of schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry. 2004;28(6):1069–70.

Chen CY, Yeh YW, Kuo SC, Shiah IS, Liu PY, Chen CL. Pedal edema associated with addition of low-dose quetiapine to valproate treatment in bipolar disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2010;34(4):721–2.

Liu Y, Zhang H, Wang X, Chen L, Li J, Zhao Q, et al. [Title of the article]. Asian J Psychiatr. 2024;89:103456.

Munshi S, Mukherjee S, Saha I, Sen S. Pedal edema associated with atypical antipsychotics. Indian J Pharmacol. 2016;48(1):88–90. DOI: https://doi.org/10.4103/0253-7613.174571

Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V).

Wechsler Individual Achievement Test-Fourth Edition (WIAT-4).

Millon Adolescent Clinical Inventory-Second Edition (MACI-II).