Case Report Clinical Case Studies and Reports Old causes still alive - A case report

Prevalence patterns for infectious diseases change over time and the testing of their presence at referral to hospitals may be reduced when the incidence rates are low. A case is presented, where a suspicion of syphilis as the maybe reason for a stabbing in a train, firstly came during the forensic psychiatric interview. This underscores the need for taking rare causes into consideration and for the use of psychiatrists, not only psychologists at forensic examination of mental illness.


Introduction
Forensic psychiatry meets a multitude of clinical presentations. The main purpose of a psychiatric investigation for the courts is to shed light on the mental health status of the accused. Whether the incumbent is deemed psychotic at the time of committing a crime is important. According to Norwegian Law, a psychotic state exempts the accused of guilt and he/she cannot be sentenced to time in prison.
Neurosyphilis is almost not present in Europe, albeit with different prevalence between countries [1]. A consequence of this fact was the abolishment of compulsory blood testing at entry to hospitals for neurosyphilis (lues serology). Prynn, et al. amply document the rarity of this sexually transmitted disease in a case presenting with severe chest sepsis, personality change, and aggression and paranoid delusions. The laboratory confirmation of neurosyphilis is recently documented in a study of 34 cases [2].

Case report
A man, 35 years of age, was arrested after knife stabbing a man unknown to him on a train in Oslo. He maintained that the man had threatened him. Observations from witnesses were to the contrary. A preliminary forensic psychiatric interview concluded with probably psychotic disease and the need for a full forensic psychiatric investigation. He was interviewed in a forensic psychiatric department by a psychiatrist and a psychologist not employed in the facility. In this facility, he was given injections of olanzapine without his consent as a needed compulsory treatment. An interpreter was needed from his native Rumanian. He was born in Rumania but did not know whom his parents were, although he thought they were Russians as one of his names was of Russian origin. He grew up with people he called gypsies and he had no schooling, but he could read and write in Rumanian. His jobs were infrequent, with little payment and of an unqualified nature. He said he most of the time went hungry. When old enough he started to ruminate around Western Europe in search of work and a place to stay. Spontaneously he revealed to the forensic psychiatric interviewer that he had used the services of prostitutes in several countries, also in his native Rumania. The psychiatrist talking to him observed that he had patches of no hair, alopecia areata, especially at the back of his head. Could this be one sign of an untreated syphilitic disorder? He had been referred to psychiatric care for psychosis in at least two European

Abstract
Prevalence patterns for infectious diseases change over time and the testing of their presence at referral to hospitals may be reduced when the incidence rates are low. A case is presented, where a suspicion of syphilis as the maybe reason for a stabbing in a train, firstly came during the forensic psychiatric interview. This underscores the need for taking rare causes into consideration and for the use of psychiatrists, not only psychologists at forensic examination of mental illness.
countries, but no records from these hospitals were available to the forensic experts. He did not receive any antibiotic treatment anywhere as far as he could remember from his infrequent contact with health care personnel.

Discussion and Conclusion
People living on the outskirts of society do not have normal access to health and social services even when in need of it. And diseases may spread through cross border travel, also when the traveler is deemed affluent. This would be the case with spread of multi-resistant microbes (MRSA). Testing of MRSA is routinely done in somatic hospitals, but not necessarily in mental hospital wards, even in the case of acute referrals. Everyone may roam from country to country within the Schengen area. Some commit crimes and are apprehended by police and courts. Their health needs may then come to attention. Whether they get access to any service is related to available means except in countries with a generous health care service covering the whole population free of charge. Giving your credit card for access depends on having one. The incumbent in the described case had none. His lifestyle may very well have exposed him to increased risk of venereal disease.
Syphilis is often described as the great imitator due to its varied clinical manifestations [3]. Psychotic symptoms may be one, as in the present case. Aggression is not necessarily significantly related to venereal diseases as syphilis [4]. Continued attention towards even rare diseases may be needed before the suspicion is awakened during a forensic interview.