title: Mania as a presenting symptom of Wilson's disease.
abstract: OBJECTIVE
  Wilson's disease commonly presents with neurological or hepatic manifestations. When it presents with only psychiatric symptoms, or with extrapyramidal symptoms secondary to neuroleptic exposure, the diagnosis of underlying Wilson's disease may be missed.
  
  
  METHODS
  An 18-year-old boy presented to the psychiatric clinic with a manic syndrome and high propensity for extrapyramidal symptoms to neuroleptic. Initial examination revealed splenomegaly and pancytopenia. Subsequent detection of Kayser-Fleischer ring and typical biochemical findings confirmed the diagnosis of Wilson's disease.
  
  
  RESULTS
  While the psychiatric symptoms came under control with lithium carbonate, extrapyramidal symptoms continue to persist even after neuroleptic withdrawal. Pancytopenia thought to be due to hypersplenism persists, and patient has developed features of liver cirrhosis. Treatment with zinc and folic acid has been started, and the patient is under evaluation for treatment with penicillamine.
  
  
  CONCLUSIONS
  The psychiatrist needs to recognize that Wilson's disease can uncommonly present with isolated psychiatric symptoms, including mania. Early and severe extrapyramidal symptoms secondary to neuroleptic exposure in an adolescent age group warrants a detailed evaluation to rule out underlying neuropsychiatric conditions.
authors.affiliation: 1Department of Psychiatry, Kasturba Medical College & Hospital, Manipal 576104, Karnataka, India.
authors.forename: Prabhat Kumar
authors.initials: PK
authors.lastname: Chand
authors.affiliation: 2Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560029, Karnataka, India.
authors.forename: Pratima
authors.initials: P
authors.lastname: Murthy