Case Presentation: A 32 year-old female with history of systemic lupus erythematosus, depression and anxiety was admitted to the medical ward with cytomegalovirus pneumonitis and viremia. On hospitalization day 21, patient had an acute change in mental status becoming nonverbal and non-interactive with examiner. Medications at the time of incident were ceftriaxone, valgancyclovir, thiamine, prednisone and warfarin. Vital signs were normal and she had non-labored breathing on room air. Exam was notable for unresponsiveness to verbal commands or painful stimuli. She displayed negativism in resisting eye and jaw opening. However, she would spontaneously open her eyes and look around the room. Pupils were dilated 8-9 mm reacting briskly to light. Doll’s eye reflex remained intact. She blinked to threat. She displayed waxy flexibility without rigidity. There were no focal neurologic deficits. She had mild left chin twitching but no myoclonus, or asterixis. Laboratory evaluation was significant for the following: white blood cell count, 10.8 x 10^9 /L (3.5-10.5×10^9/L) consisting of 20% atypical lymphocytes (0-3%); glucose, 111 mg/dL (70-100); ammonia, 11 mcmol/L (0-22); and thyroid stimulating hormone, 4.25 MIU/L (0.3-4.2). Additionally, double stranded DNA antibodies titers were elevated, core reactive protein (CRP) was 45.5mg/L (0-8.0), and complement 3 and 4 levels were low. Cerebrospinal fluid was normal and no viral DNA was detected. Non-contrast computed tomography of the head was unremarkable. Electroencephalogram showed no seizure-like activity. A 1mg dose of IV lorazepam was administered, after-which patient instantly became interactive again answering questions and following commands. She was subsequently started on lorazepam 1mg by mouth three times per day and her symptoms did not recur during her hospitalization.
Discussion: Catatonia is a severe neuropsychiatric syndrome affecting the motor system. It is a significant cause of morbidity, increased hospital stay, and increased healthcare cost. Catatonia is diagnosed by DSM-5 criteria when at least 3 of the following symptoms are met: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypy, purposeless motor activity, grimacing, echolalia, and echopraxia. Among the symptoms of catatonia, waxy flexibility is one that is relatively uncommon but highly specific for the diagnosis. Catatonia may occur following stressors such as prolonged hospitalizations. Patients with depression are more prone to catatonia, and various neuropsychiatric are seen in lupus, however catatonia is quite rare. Treatment for catatonia is benzodiazepines. Our patient instantly responded to a one-time lorazepam administration, which supports the diagnosis.
This case illustrates the differential exercise patients with suspected catatonia. The differential for catatonia is broad including encephalopathy, delirium, serotonin syndrome, neuroleptic malignant syndrome, status epilepticus, stroke (e.g. locked-in-syndrome), hypo/hyperglycemia, and hyperammonemia. Drugs were also considered. This patient was on prednisone, which can cause excitability or agitation, but catatonia has never been reported.
Conclusions: This case illustrates the importance to maintain a high index of suspicion for catatonia in hospitalized patients who are unresponsive with waxy flexibility, as early treatment with benzodiazepines is an effective treatment and aids in confirming the diagnosis.