Case Presentation: A 44-year-old female with CKD5, ESRD, HIV on ARV (abacavir, dolutegravir, lamivudine) was admitted for sepsis and diagnosed with an iliac vein hematoma. She underwent three different operations, and
on the third day after the last procedure she stopped talking or communicating with family, staff and
refused to eat. In the days prior, she had been verbal, and oriented to situation, person, and place.
Patient had been hospitalized several times before, due to her extensive medical history, but had never
experienced this abrupt change in behavior before. She had no past psychiatric or epileptic illness.
Patient lived with her family and was the caregiver of her three children at home.
She had no fever, and vital signs were within normal limits. Mental status assessment revealed that patient was difficult to arouse, uncooperative, and had a flat effect. She maintained poor eye contact. There was prominent psychomotor retardation; she stayed in bed, and her movements were slow.
Patient was non-verbal, did not have spontaneous speech and did not answer any questions. She did not follow verbal commands. Patient was refusing to eat, and the only verbal utterance she would say was “ouch” in response to painful stimuli. Examination of her muscle tone exhibited op
positional paratonia /gegenhalten. A Bush-Francis catatonia scale indicated 16 points.
Laboratory and imaging data were unrevealing. No medications that could cause this presentation were
identified. A diagnosis of catatonia was made. She was given a dose lorazepam 2mg IV, a remarkable recovery was observed over an hour after the
medication’s administration. She start to communicate verbally with family and staff, asked for food
and took all her medications. Her affect became reactive; she was alert with noticeable spontaneous movements. Continuous evaluation for the first 1-2 hours after the lorazepam detected that the catatonia was fully resolved. She was treated another day with oral lorazepam and was discharged home in stable condition. She remains symptom free for over one year since discharge and is preparing
To receive a kidney transplant. She did not relapse into catatonia.
Discussion:
Catatonia is not commonly observed among hospitalized patients and historically was associated
primarily with schizophrenia, and also with severe mood episodes of unipolar or bipolar disorder.
However, some cases are of non-psychiatric origin or idiopathic.
The diagnosis requires psychiatrist consultation, thorough evaluation, extensive laboratory and imaging studies in order to exclude organic etiology. Catatonia should be suspected if the patient demonstrates muscle rigidity, mutism, negativism and stupor. If catatonia is suspected, a challenge with a benzodiazepine (i.e. intravenous lorazepam) should be conducted. Evaluation prior to the first couple of hours after the administration of the drug should show a rapid improvement in the mental status. If diagnosis is confirmed, benzodiazepines or electroconvulsive therapy can be implemented for treatment
Conclusions: Catatonia is a complex neuropsychiatric condition manifested by motor, behavioral and autonomic abnormalities with multiple possible etiologies. Early recognition and increased awareness of its signs and symptoms as well as mindfulness of the available screening tools and early psychiatric consultation are essential in prompt diagnosis and providing timely intervention to mitigate hospital costs, avoid complications and overall improve outcomes.