CASE REPORT R. JEFFREY DAVIS, D.O. JEFFREY L. CUMMINGS, M.D. BARNETD. MALIN, M.D. THOMAS GARRICK, M.D. Prolonged psychosis with first-rank symptoms following metrizamide myelography Since its introduction in 1969,' metrizamide has become a widely used radiographic contrast agent for intrathecal vi- sualization of CNS structures. The incidence of major ad- verse side effects following its use is relatively low, but mental status changes are far more common than with ear- lier agents. U Confusion, diminished attention, disorienta- tion, anxiety and depression, incoherent speech, and per- ceptual aberrations (including visual and auditory halluci- nations) have been described. J.6 Typically, these side effects are short-lived, rarely lasting longer than a few days. This report describes an unusually prolonged change in menta- tion accompanied by hallucinations, delusions, and a chor- eiform movement disorder that began following a metriza- mide myelogram. The organic psychosyndrome was unique in that it was dominated by Schneiderian first-rank symp- toms. Case report A 66-year-old man was admitted to the hospital for evalua- tion of neck and back pain. He had a history of peptic ulcer disease and of intermittent alcohol abuse but had main- tained sobriety for six months prior to admission. He had no From the department of neurology. UCLA (Dr. Davis); the neuro- behavior unit. West Los Angeles VAMC (Brentwood Division) and the department of neurology. UCLA (Dr. Cummings); the depart- ment of psychiatry and biobehavioral sciences. UCLA. and the psychiatry service. West Los Angeles VAMC (Dr. Garrick. Wads- worth Division; Dr. Malin. Brentwood Division). Reprint re- quests to Dr. Cummings. Neurobehavior Unit (691 /Bl 11). West Los Angeles VAMC (Brentwood Division). 11301 Wilshire Blvd.. Los Angeles. CA 90073. MAY 1986-VOL27-N05 history of psychiatric illness, and there was no family history of neurologic or psychiatric disorders. A metrizamide myelogram (8 mL, 250 mgl/mL) was per- formed through a lumbar puncture site. Twelve hours after the procedure, the patient developed a mild headache. be- came disoriented to time and place. and told the staff that colors seemed very bright. The next morning, he com- plained that his thinking seemed dominated by the number 3 and sequences of 3. Although he was able to walk without difficulty, he remarked that his legs would not move, a prob- lem he attributed to poisoned food and water. He was treat- ed with 5 mg of haloperidol twice daily, improved over the next two days, and was discharged from the hospital without medication. Six days later, his family brought him back to the hospital. At home he had gradually improved but had not returned to normal and had intermittently complained of hearing voices. He also had unusual persistent movements of his hands and feet. The day before admission he became agitated, com- plained of hearing voices, and believed that signals from the television set controlled his thoughts. When examined in the emergency room, he was disoriented to time and place and could follow only simple commands. He was preoccupied with "a flashing sign on the ceiling" that blocked histhoughts until he could trace the proper geometric sequence and lo- cate a specific dot that allowed his thoughts to emerge. Neu- rologic examination and laboratory studies including a CT scan of the head and lumbar puncture were normal. An EEG revealed excessive a-range slowing. The patient was placed on 5 mg of haloperidol three times daily. The following day (nine days after the myelogram), he was noted to have asymmetric, uncontrolled choreiform movements of the hands. A repeat EEG revealed a normal 10 to 12 Hz a-rhythm with superimposed a-range slowing. 373