Malignant Catatonia and Aphasia Follow Multiple-Drug Overdose

By Shenai, Neeta; White, Crystal et al. | Current Psychiatry, December 2015 | Go to article overview

Malignant Catatonia and Aphasia Follow Multiple-Drug Overdose


Shenai, Neeta, White, Crystal, Azzam, Pierre, Gopalan, Priya, Solai, LalithKumar K., Current Psychiatry


Two weeks after an overdose, Ms. M, age 37, develops malignant catatonia. Although her catatonic symptoms resolve with ECT, she shows word-finding difficulty. How would you proceed?

[CASE] Improvement, then decline

Ms. M, age 37, is brought to the hospital after her husband found her at home, after an unknown duration of impaired consciousness. Her husband reports that Ms. M had normal cognitive functioning before this event, with no difficulty completing activities of daily living. Ms. M's medical and psychiatric histories are notable for type 2 diabetes mellitus, unspecified bipolar disorder, and opioid, cocaine, and alcohol use disorders. Her medications include paroxetine, 40 mg/d, and gabapentin, 1,200 mg/d.

First admission. Poor inspiratory effort and oxygen saturation of 70% leads to emergent intubation. Serum laboratory studies reveal a white blood cell (WBC) count at 10,900/pL and creatinine phosphokinase level of 25,000 U/L. Urine drug screen is positive for tetrahydrocannabinol, cocaine, and opioids.

Ms. M is admitted to the ICU for management of rhabdomyolysis and multi-organ system failure, including acute hypoxic kidney injury.

By hospital Day 7, the tube is extubated with no recorded physical neurologic deficits. Mental status exam is normal, except for impaired memory of events surrounding the admission. Ms. M is discharged home with a recommendation for outpatient follow-up.

2 Weeks later. Ms. M is brought to the emergency department after a progressive decrease in social interaction, limited oral intake, decline in activities of daily living, and urinary incontinence. Results from laboratory studies are within normal limits; brain MRI is negative; EEG shows generalized moderate slowing.

During psychiatric evaluation, Ms. M is mute and staring continuously. Examination reveals oppositional paratonia (gegenhalten), catalepsy, prominent negativism, and waxy flexibility, all suggestive of catatonia. IV lorazepam is initiated at 1 mg every 8 hours, titrated to 2 mg, 3 times a day.

Ms. M is transferred to a psychiatric hospital for further treatment of catatonia.

Second admission. Evaluation with the Bush-Francis Catatonia Rating Scale supported a diagnosis of catatonia, with the presence of >3 features from the 14-item screen and a score of 16 on the 23-item rating scale. (1) After titrating lorazepam to 9 mg/d with minimal therapeutic impact, the psychiatry team consults the electroconvulsive therapy (ECT) service, who deems Ms. M to be an appropriate candidate and petitions for court-ordered ECT.

On hospital Day 8, Ms. M has a fever of 104[degrees]F, tachycardia at 180 beats per minute, increased rigidity, and a WBC count of 17,800/pL. She is transferred to the ICU, with a presumptive diagnosis of malignant catatonia.

The medical evaluation, including general laboratory studies, EEG, and spinal fluid analysis, is unremarkable. Because of vital sign instability, 2 ECT treatments are completed in the general hospital before Ms. M resumes psychiatric inpatient care.

By the tenth ECT treatment, Ms. M is no longer febrile and experiences no further autonomic instability or psychomotor features of catatonia. Despite these improvements, she is noted to have persistent word-finding difficulty.

Which test would you order as the next step in your work up?

a) EEG

b) lumbar puncture

c) MRI

d) CT

The authors' observations

In approximately 25% of cases, catatonia is caused by a general medical condition (2); as such, a comprehensive medical workup is vital for assessment and management of catatonic patients. In Ms. M's case, we considered several medical causes, including nutritional deficiency, infection, a toxin, renal or hepatic impairment, hypothyroidism, seizure, and stroke. Evaluation included measurement of thyroid-stimulating hormone, vitamin [B. …

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