A Rare Case: Is It Hemodialysis Encephalopathy, Dialysis Anxiety, or Both?

TL;DR

A 59-year-old woman with mental status changes and seizures was diagnosed with both hemodialysis encephalopathy and dialysis-related anxiety, a rare and complex case.

Contribution

This case highlights the rare comorbidity of hemodialysis encephalopathy and dialysis anxiety, which is uncommon in the literature.

Findings

The patient's symptoms were partially explained by hemodialysis encephalopathy confirmed via EEG and CTH.

Anxiety symptoms were alleviated with anti-anxiety medication, suggesting a concurrent diagnosis of dialysis anxiety.

Not all symptoms were explained by tests, requiring clinical judgment and process of elimination for diagnosis.

Abstract

We present a case of a 59-year-old female who presented with progressively worsening altered mental status, seizures, and neuropsychiatric symptoms. Over the course of her emergency visit and admission to the hospital, laboratory tests failed to find an offending agent to her presentation. Her clinical presentations supported the diagnosis of encephalopathy, but the actual underlying cause was not found. After careful exclusion of bacterial, viral, and other types of encephalopathy, hemodialysis encephalopathy was a possible diagnosis. The presentation and symptoms of our patient led to a wide range of differentials, and a high index of suspicion was needed throughout her admission in order to obtain the appropriate tests. Computed tomography head (CTH) and electroencephalogram (EEG) were performed and showed results that supported our diagnosis of hemodialysis encephalopathy. Despite the supportive testing results of the brain, there are still some neuropsychiatric symptoms of our patient that remain unexplained. This led us to account for the physical exam, clinical judgment, and the process of elimination to diagnose our patient with anxiety due to dialysis concurrent with hemodialysis encephalopathy. Despite little evidence in the literature supporting the presence of anxiety disorders in patients receiving dialysis, our patient showed alleviated clinical presentation after being prescribed an anti-anxious medication, making this presentation uncommon. In this rare case, we present a patient with possible comorbidity of both hemodialysis encephalopathy and dialysis anxiety that the result from EEG and other tests failed to explain all the symptoms our patient experienced.