174 Catatonia Complicated by Encephalopathy-Diagnostic and Treatment Challenges

Abstract:

The term Catatonia was coined by Kraepelin in 1893 and was categorized as a subtype of dementia praecox. Bleuler in 1906 redefined it as catatonic Schizophrenia. Over the period of time by accumulating evidence of various case reports and studies its apparent that catatonia is not only seen in Schizophrenia, Affective disorders but is also seen secondary to various medical problems. There is very limited literature describing catatonia in the presence of neurological problems like Encephalopathy. The pathophysiology of Catatonia remains unclear. Given the involvement of common substrates like GABA, Dopamine and glutamate that are altered in many neurological problems and catatonia the differentiation and treatment become complicated.

METHOD:

We present the case of a 32-year-old male with bipolar II disorder, who was initially went through elective cholecystectomy complicated by bowel perforation and septic shock. Patient had to be intubated and had complicated ICU stay. Various consultation services including Neurology, Infectious disease, psychiatry, Intensivist got involved to address the multiple medical comorbidities like sepsis, encephalopathy and apathy. In spite of improving EEG showing resolving encephalopathy patient remained mute, immobile, not following any instructions, with no oral intake. All imaging including CT scan and MRI repeated 3 times over the period of time were negative. Patient’s psychiatric medications that includes Wellbutrin was held to minimize the risk of seizures. Patient’s neuro exam had positive Babinski and pupils dilated. He also had autonomic dysfunction. There were no clear-cut symptoms to enable us differentiating hypoxic brain injury and Malignant catatonia. We considered the differential diagnosis of Catatonia and initiated Ativan IV challenge.

RESULTS:

The patient was reassessed one hour after administration of lorazepam. He displayed slight response to Ativan by moving his fingers in the first 24 hrs. We had to continue to titrate the Ativan to very high doses in the period of 3 weeks with a very slow but good response.

CONCLUSION:

This case reflects the intricacy in diagnosing Catatonia complicated by Encephalopathy and the challenges in its treatment. We want to add on to the current literature on Catatonia masked by multiple medical comorbidities and the challenges of treatment