A 68 year old woman with a past history notable for recurrent urinary tract infections presents with one day of confusion, odd postures, mutism, and subjective fever. In the Emergency Department, she was febrile to 103o, tachycardic, and appeared restless, with odd purposeless movements of her extremities. She was only able to follow one step commands, was nonverbal, and had waxy flexibility. Her Bush Francis Catatonia Rating Scale score was 18. Her labs were notable for a urine analysis showing large leukocyte esterase, many white blood cells, and many bacteria. She was admitted to medicine for intravenous (IV) antibiotics for treatment of her urinary tract infection (UTI). While her fever and leukocytosis improved, her Bush Francis Catatonia rating scale did not. On day 3 she was treated with intravenous lorazepam 1 mg. Within 10 minutes, she became interactive, conversant, and oriented to self and location. She was then started on a course of oral chlordiazepoxide and her mental status improved back to her baseline.
Discussion:
Delirium with catatonic features is a rarely recognized clinical presentation with limited documentation in the medical literature. Historically, catatonia has been characterized as a subtype of schizophrenia, which led clinicians and investigators to associate catatonia with underlying psychiatric illness. Catatonia is now accepted in DSM-5 as a feature of either medical or psychiatric disease, and should be suspected in patients presenting with any number of the following: stupor, catalepsy, waxy flexibility, mutism, negatism, posturing, odd mannerisms, stereotyped movements, grimacing, echolalia, and echopraxia.
Narrowing the differential in this patient between delirium and delirium with catatonic features is crucial because the treatment varies drastically. The mainstay of treatment for delirium involves treating the underlying cause, in this case antibiotics for the urinary infection. Benzodiazepines are generally avoided as they can exacerbate delirium. In contrast, the treatment of catatonia is benzodiazepines. When delirium with catatonic features presents, both should resolve with the treatment of the underlying cause of delirium. For this patient, the symptoms of catatonia persisted despite the resolution of her UTI and she returned to baseline only when she was treated with benzodiazepines.
Conclusions:
Catatonia a constellation of symptoms that is often diagnosed in the setting of a primary psychiatric disorder; however there is a broader differential, which includes delirium and other medical conditions. Similar to delirium, delirium with catatonic features usually improves with treatment of the underlying cause. If it does not improve, you should consider a trial of benzodiazepines.