Case Based for November & December

Catatonia

A 60 year old female with history of bipolar disorder with aggressive behavior, hypertension, and chronic kidney disease, was brought in by ambulance after her husband found her unresponsive on the floor. He reports that she was diagnosed with COVID two weeks ago. She had not had anything to eat or drink for two days. Her vital signs were: T 98.9, P 72, R 16, BP 148/88, SpO2 96% on RA. She was responsive to pain in the ED and would occasionally follow commands but was never alert or able to answer questions. WBC 18.7, Na 177, glu 145, BUN 135, crt 3.71, venous pH 7.36, lactic 1.8. CT head showed no acute findings. There were no beds available at larger facilities for transfer. She was started on D10 ¼ NS @ 160ml/hr. Her mental status waxed and waned but never returned to baseline. The following day she was finally transferred to Sacred Heart, where she remains weeks later. Her sodium and renal function were corrected. She was diagnosed with psychosis with catatonia and is now on a court-ordered hold for ECT on the psych service.

Discussion: Catatonia is a behavioral syndrome marked by inability to move normally due to underlying psych or general medical disorder. The signs are heterogeneous but can include immobility, mutism, decreased alertness and responsiveness, negativism (resistance to attempts to move or to instructions), waxy flexibility, posturing, excessive purposeless motor activity, staring, robotic voice, and echolalia (senseless repetition of other person’s utterances) or echopraxia (senseless repetition of other person’s movements). These patients have frequent dehydration/malnutrition, DVT/Pes, contractures, pressure ulcers, and excitement/impulsivity, which all need to be managed. Antipsychotics and dopamine blocking agents should be avoided, as they can cause neuroleptic malignant syndrome. Treatment with benzodiazepines is the mainstay, usually lorazepam 1-2mg IV TID. If there is no response in a week, switching to ECT is recommended. If the patient is already on a benzodiazepine at home, the dose should be 1-2 mg in addition to their normal, maintenance dose. If no response, the dose is increased by 3mg every 1-2 days, most patients requiring total dose of 6-21mg/day. Malignant catatonia is life-threatening and includes fever, hypertension, cardiopulmonary instability, and rigidity. It is fulminant and progresses rapidly. It requires ICU admission and aggressive management, including benzos and ECT. The findings overlap with NMS.

SUMMARY AND RECOMMENDATIONS

●Catatonia is a behavioral syndrome marked by an inability to move normally that is associated with many psychiatric, neurologic, and general medical disorders. Signs of catatonia are listed in the tables (table 1 and table 2). The three primary subtypes of catatonia are retarded, excited, and malignant. (See ‘Definition of catatonia’ above and “Catatonia in adults: Epidemiology, clinical features, assessment, and diagnosis”.)

●Treatment of acute catatonia generally occurs in hospital settings where the patient’s general medical health can be monitored and optimized. Malignant catatonia in particular is life-threatening and generally warrants admission to an intensive care unit. (See ‘Setting and management’ above.)

●Concurrently treating the underlying psychiatric or general medical disorder along with the catatonia may improve outcomes. Clinicians should avoid using dopamine blocking drugs, even if patients are psychotic, impulsive, or aggressive. Treating catatonia with an antipsychotic is a risk factor for the neuroleptic malignant syndrome (NMS). Antipsychotics are contraindicated in malignant catatonia. (See ‘Underlying disorder’ above and ‘Avoid dopamine blocking drugs’ above.)

●Mortality in malignant catatonia may increase if electroconvulsive therapy (ECT) does not begin within five days of symptom onset. For patients with malignant catatonia, we recommend ECT rather than a benzodiazepine (algorithm 1) (Grade 1C). A benzodiazepine should be administered during preparations for ECT; if malignant catatonia improves significantly with the benzodiazepine during the first 24 to 48 hours, it can be continued in lieu of ECT. (See ‘Treatment algorithm’ above and ‘Malignant catatonia’ above.)

●For patients with nonmalignant catatonia, whether the behavioral phenotype (motor disturbance) is retarded or excited, we recommend a benzodiazepine rather than ECT (Grade 1C). For retarded or excited catatonia that does not respond to a benzodiazepine, we suggest ECT rather than other medications (Grade 2C). (See ‘Treatment algorithm’ above and ‘Nonmalignant catatonia’ above.) ●The benzodiazepine used most often is intravenous lorazepam 1 to 2 mg three times per day, which is increased by 3 mg per day every one to two days. A dose of 6 to 21 mg daily is effective for most patients, but a dose of 30 mg per day is occasionally necessary. The benzodiazepine is usually continued orally at the effective dose for three to six months and then tapered and discontinued. Following remission of catatonia, the benzodiazepine should be continued if an antipsychotic drug is used to treat the underlying disorder. (See ‘Benzodiazepine safety and administration’ above.)

●There are no absolute contraindications to ECT. For catatonic patients with motor immobility and muscle damage, a nondepolarizing muscle relaxant is used in order to eliminate the risk of transient hyperkalemia associated with the use of the succinylcholine. ECT is generally given three times per week on alternating days, but malignant catatonia may initially require daily treatments. ECT is typically administered at least six times with bilateral electrode placement and brief pulse current. (See ‘Electroconvulsive therapy safety and administration’ above.)

●Retarded and excited catatonia both appear to have a generally favorable prognosis, especially in patients with an underlying bipolar or depressive disorder or toxic-metabolic disorder. By contrast, malignant catatonia may result in permanent morbidity, and death rates of up to 20 percent have been reported. (See ‘Long-term prognosis’ above.)

This is for informational purposes only. For medical advice or diagnosis, consult a physician

 

Neuroleptic Malignant Syndrome (NMS)

The patient is an 86-year-old male brought into the ER by family for history of a fall and altered level of consciousness.

HPI from the family: The patient does have a caretaker (family member) and had been in bed when the caretaker got into the shower. When the care take finished the shower, the patient was found down on the floor and had been incontinent of urine and stool. The shower was estimated to be no longer than 10 to 15 minutes. Other family members happened to arrive simultaneously as the caretaker was finding the patient.  The family helped the patient up and noted that he was covered in stool and took him to the shower and cleaned the patient off. They then dressed him in clean clothes. The family noted that the patient seemed more confused than normal and brought him to the ER for evaluation. The patient could not give a history.

Selected PMHx:

1. Hypertension
2. Progressive dementia with recent aggressive behavior.
3. GERD
4. Chronic low back pain
5. Intracranial bleed
6. History of falling.

Selected PSHx

1. Craniotomy for Sub-dural evacuation (5 years prior)
2. Appendectomy
3. Tonsillectomy and Adenoidectomy

Medications:

1. Metoprolol Succinate 25 mg daily
2. Quetiapine 12.5 mg daily
3. Omeprazole 20 mg daily
4. Ibuprofen 600mg Q8hours prn pain

 

Allergies: No Known Drug

Vital signs: T = 99.3, HR = 92, Resp = 18, BP 146/83 HT = 5 ft 10in, WT = 76.3 Kg

Note Patient’s Temp did reach 100.4F once in the ER and was treated with Acetaminophen IV. The patient was afebrile at all other measurements. The remaining vital signs remained stable and within normal limits during the stay in the ER.

 

P.E. (Pertinent positive findings) patient not able to cooperate with exam

Head: Negative

Eyes; Negative

Oral: Negative (difficult exam)

Coronary: Negative

Resp: Negative

Abdomen: no reaction to exam

Rectal: Unable due patient non-cooperation

Extremity/Muscular: Will spontaneously move extremities but seemed to resist any passive effort to move extremities. Pulses palpable and without cyanosis or pallor. Abrasion on left lateral knee. No palpable bony deformity.

Neurological: Awake. MAE, Orientation: not able to determine (baseline oriented to person per family) Does not follow commands. GCS = 12

 

Radiology:

CT head: Old lacunar infarcts, without acute findings.

C-Spine: No fracture

CT Chest, Abdomen, and Pelvis (with contrast): No Acute findings

Plain films of extremities: No Fractures, dislocation, subluxation seen.

 

Laboratory (Selected)

WBC = 22.3, H&H 12.4/37.3 PLT 227

CMP Unremarkable except (CO2 = 22) AST mildly elevated

Lactic Acid 3.9

U.A. Unremarkable

 

The patient was felt to have an occult Sepsis, was provided with Rocephin 1gm IV and placed on the Observation service.

The following morning on the Observation service showed:

Physical exam unchanged: N.B.: thorough exam of the skin did not show any areas of erythema (including perineum and perirectal area).  Patient clenches anal sphincter with palpation so unable to perform rectal digital exam.

Labs: WBC 16.4 H&H unremarkable, Platelet normal

CMP Unremarkable CO2 within normal limits. Renal function normal, AST elevated at 75

Lactic Acid 2.1

CPK 3465

Patient’s home medications were held (blood pressure and heart rate continued within normal range) and Rocephin was continued. Normal saline was started to treat the Rhabdomyolysis. Patient placed on Acute Service. No evidence of acute infection was found.

Afternoon labs WBC = 12.1 Lactic Acid 1.9, AST 47

 

Hospital day 2 patient awake and alert, Oriented X 1 to (person – baseline per family). Exam shows passive movement of all extremities through full range of motion without pain. Active extremity movement through a full range of motion motor 5/5. Patient Metoprolol resumed.

 

The patient responded well to hydration and the Rhabdomyolysis resolved over three days. No evidence of acute infection was found throughout patient hospital stay. AST returned to normal limits.

 

Diagnosis: Neuroleptic Malignant Syndrome due to a second-generation antipsychotic medication.

 

Per Up-To-Date

Neuroleptic Malignant Syndrome (NMS)

The etiology of the syndrome is not completely understood but is thought to be caused by dopamine antagonist agents

A neurologic emergency characterized by:

• Mental Status Changes – usually the initial symptom and takes the form of an agitated delirium and confusion rather than psychosis.
• Muscular rigidity – usually generalized and often extreme (lead-pipe rigidity) but may take the form of cogwheel rigidity and tremor.
• Hyperthermia is a defining symptom (90%) of cases temperatures of 38C (100.4F) but may exceed 40C (104F).
• Autonomic instability – typically tachycardia (88%), labile or high blood pressure (61-77%) and tachypnea (73%) Dysrhythmia may occur, and diaphoresis is often profuse.
• Less typical manifestations:

1. Rigidity milder
2. Elevated temperature milder or absent
3. Elevated CPK
4. Leukocytosis
5. Mild elevations of LDH, alkaline phosphatase, and liver transaminases
6. Electrolyte abnormalities
7. Metabolic acidosis
8. Rhabdomyolysis
9. Low serum Iron

• Of note: One of the drop-down list notes “lack of a finding of a different cause for symptoms” as part of the diagnostic tree.
• Second-Generation Antipsychotic medications are more frequently implicated in a milder presentation that the First-Generation Antipsychotics.

Treatment is discontinuation of dopamine antagonist (or resume dopamine agonist therapy) largely supportive with addressing and control of Hyperthermia, Hypertension.

1. Benzodiazepines to control agitation.
2. Dantrolene for moderate to severe muscle rigidity with elevated CPK.
3. Normal Saline is the fluid of choice to treat Rhabdomyolysis
4. Bromocriptine or Amantadine may be added for moderate to severe cases
5. Maintain euvolemia.

 

Written by Marc Bracy

ERx Clinical Partners Medical Director, Northern Cochise Community Hospital, Willcox, AZ

 

This is for informational purposes only. For medical advice or diagnosis, consult a physician