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

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.