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Bipolar II disorder as the initial presentation of CADASIL: an underdiagnosed manifestation

Authors Wang J, Li J, Kong F, Lv H, Guo Z

Received 22 May 2017

Accepted for publication 10 July 2017

Published 14 August 2017 Volume 2017:13 Pages 2175—2179


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Professor Wai Kwong Tang

Jianjun Wang,1 Jinfang Li,2 Fanxin Kong,2 Hanqing Lv,3 Zhouke Guo2

1Department of Neurology and Psychology, the Fourth Clinical College, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, People’s Republic of China; 2Department of Neurology and Psychology, Shenzhen Hospital of Chinese Medicine, Shenzhen, Guangdong, People’s Republic of China; 3Medical Imaging Department, Shenzhen Hospital of Chinese Medicine, Shenzhen, Guangdong, People’s Republic of China

Abstract: Mood disturbances have been documented in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). The highly varied morbidity indicates that the affective symptoms in CADASIL have not been cataloged systematically, leading to ineffective treatment, affecting the patients’ quality of life, and possibly resulting in suicide. We present a case of CADASIL with bipolar II disorder as the first manifestation. A middle-aged female reported recurrent depressive episodes and appeared treatment resistant to adequate dosages and durations of antidepressants. Following a structured psychiatric interview and neuropsychological assessment, a past episode of hypomania was identified. Added treatment with sodium valproate alleviated most symptoms. Considering late-onset bipolar disorder with unexplained decline in cognition, a medical history of migraine, and a suspected family history of stroke, further cranial magnetic resonance imaging scan was performed and revealed severe leukoencephalopathy, prompting further investigation. The diagnosis was revised to CADASIL after Arg587Cys NOTCH3 mutation was confirmed. This case highlights the evolving process of affective disorder diagnosis and underlying organic etiologies. Based on the overlap of white matter hyperintensities, NOTCH3 mutation, and valproate therapy in bipolar disorder and CADASIL, bipolar II depression may be a poorly recognized manifestation of CADASIL. Well-designed clinical trials are warranted to verify the current findings.

Keywords: leukoencephalopathy, bipolar II disorder, hypomania, NOTCH3, white matter hyperintensities

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