Diagnostic dilemma of cognitive decline in a young female: considering congenital rubella, depressive disorder, and moyamoya disease Robin Victor 1 , Vrinda Saxena 2 , Shailendra Raghuvanshi 3 , Ravi Gupta 4 1 Department of Psychiatry, Muzafarnagar Medical College, Muzafarnagar, Uttar Pradesh, India, 2 Department of Psychiatry, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India, 3 Department of Radiology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India, 4 Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India Correspondence: Dr. Robin Victor, Assistant Professor, Department of Psychiatry, Muzafarnagar Medical College. Opp. Begrajpur Industrial Area, 115 Km Stone, Delhi-Dehradun Road, Muzafarnagar-251001, Uttar Pradesh, India. robinvictor111@gmail.com Received: 19 April 2018 Revised: 24 February 2020 Accepted: 4 March 2020 Epub: 13 March 2020 DOI: 10.5958/2394-2061.2020.00014.2 Abstract We report a case of a 20-year-old young female patient from North India presenting with headache, decline in scholastic performance, irritability, and low mood, and having a history of hemiparesis, who had rubella infection in her antenatal period, who was investigated and diagnosed as persistent depressive disorder (PDD) with left-sided hemiparesis in remission with moyamoya disease (MMD) based on history, examination, and relevant investigation (magnetic resonance imaging [MRI] brain/magnetic resonance [MR] angiogram). We highlight the difculties we faced in attributing whether the cognitive decline was due to congenital rubella, PDD, MMD, or a combination of any of these three diagnoses. Keywords: Paresis. Rubella. Comorbidity. India. INTRODUCTION Moyamoya disease (MMD) is a chronic progressive occlusive disease of the circle of Willis arteries that leads to the formation of the collateral vasculature at the base of the brain and is ofen an important predisposing cause of stroke in young age.[1] Terms such as “moyamoya syndrome” and “angiographic moyamoya” are ofen used when the disease is associated with comorbid conditions.[2] MMD is a rare disorder with prevalence of 0.086/100,000 population in the United States of America which was signifcantly lower than the 0.35 reported in the nationwide Japanese survey.[3] In India, prevalence data is not available. Congenital rubella syndrome consists of sensorineural hearing defects, eye abnormalities such as cataracts, microphthalmia, retinopathy along with heart defects - the most encountered one being patent ductus arteriosus.[4] It rarely also afects the brain and presents as progressive rubella panencephalitis (PRP) or subacute sclerosing panencephalitis (SSPE). We are presenting a case of a young female presenting with progressive cognitive decline and loss of interest in daily activities for four years. She had sufered hemiparesis four years back and was operated for congenital cataract. CASE SUMMARY A 20-year-old female was brought by her parents with the complaints of headache and decline in scholastic performance for past two and half years. Te complaints were persistent and progressive in nature. She was having difculty in academic performance with difculty in understanding basic concepts of her syllabus with frequent forgetfulness and decreased attention span, difculty in planning things and taking decisions following which she underperformed in her annual examinations of college. She also had episodic dull headache over the frontotemporal area with each episode lasting for two to three hours, which was mild in severity aggravated while studying and used to subside on itself. Frequency of headache was initially two to three episodes per week but for last three ISSN 2394 - 2053 (Print) ISSN 2394 - 2061 (Online) RN: 143216 (RNI) www.ojpas.com CASE STUDY Open Journal of Psychiatry & Allied Sciences