Malignant catatonia

  • Severe form of catatonia characterized by extreme rigidity, hyperthermia, autonomic instability and altered mental status
  • Frequently misdiagnosed as neuroleptic malignant syndrome
  • Occurs without exposure to dopamine receptor blocking medication
  • Severe catatonia with high fever may last for several days, followed by severe parkinsonism, stupor and death
  • If promptly recognized and treated, symptoms resolve within hours to days

Diagnosis

According to the DSM-IV, catatonia can be diagnosed as a schizophrenia subtype and in the context of major mood disorders. It is however frequently observed in other psychotic disorders and as a complication of general medical conditions (eg brain tumor or hepatic encephalopathy).

Catatonia is under-recognized and under-diagnosed in both psychiatric and medical patients.

The DSM-IV does not offer any guidance in distinguishing benign from malignant catatonias.

Clinical features of malignant catatonia

  • Hyperthermia
  • Catatonic excitement or stupor
  • Negativism, mutism, catalepsy, posturing, echolalia, echopraxia
  • Rigidity
  • Altered consciousness
  • Autonomic instability (tachycardia, labile blood pressure, tachypnea, diaphoresis)

Laboratory findings in malignant catatonia

  • CPK elevation, leukocytosis and low serum iron are the most consistent
  • Elevated creatinine, hyponatremia, hypernatremia, dehydration are less consistent

Always consider catatonia when presented with an immobile, mute, rigid patient who nonetheless appears alert and attentive or when confronted with a patient in an extreme state of excitement.


The presence of a febrile catatonia is especially important to recognize early as it may be a harbinger of malignant catatonia.

Differential

  • Non-catatonic stupor
  • Encephalopathy
  • Stroke
  • Stiff-person syndrome
  • Parkinson’s disease
  • Locked-in syndrome
  • Malignant hyperthermia
  • Status epilepticus
  • Autistic disorder
  • Severe obsessive-compulsive disorder
  • Elective mutism

Each of the conditions listed may coexist with catatonia.


Conditions associated with catatonia

  • Psychiatric disorders: schizophrenia, mood disorders, periodic catatonia, other psychotic disorders
  • Cerebrovascular disorders: basilar artery thrombosis, bilateral hemorrhagic stroke in temporal lobes or anterior cingulate gyri
  • Normal pressure hydrocephalus
  • Absence status epilepticus
  • Multiple sclerosis
  • Limbic encephalitis
  • Anoxic brain damage
  • Brain tumors: pinealoma, glioma of the 3rd ventricle or involving the splenium of corpus callosum, midbrain angioma
  • Head trauma
  • Infections: viral hepatitis, septicemia, Borrelia encephalitis, viral encephalitis, bacterial meningoencephalitis
  • Metabolic disorders: uremia, Addison’s disease, Cushing syndrome, Hyperthyroidism, Wernicke’s encephalopathy, SLE
  • Postoperative states
  • Toxic and drug-related disorders

Workup

  • Complete blood count
  • Electrolyte status
  • BUN and creatinine
  • CPK
  • Serum iron
  • Urinalysis
  • Blood and urine cultures
  • CSF analysis and cultures
  • Chest X-ray
  • EEG
  • Head CT

Management

  • Supportive care. Monitor vitals, hydrate, treat fever with antipyretics and passive cooling
  • Administer lorazepam 2mg every 3 to 8 hours. Most patients (50-70%) respond within 24 hours
  • Electroconvulsive therapy (ECT) may be indicated as early intervention when treating malignant or excited-delirious forms of catatonia or in cases refractory to benzodiazepines
  • Dantrolene or bromocriptine may be used in combination with ECT
  • Antipsychotic medication should be withheld until after resolution of malignant catatonia



References

  • Catatonia. II. Treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand. 1996;93(2):137–43 doi: 10.1111/j.1600-0447.1996.tb09815.x
  • Catatonia: diagnosis, classification, and treatment. Curr Psychiatry Rep 2010;12(3):180-5. doi: 10.1007/s11920-010-0113-y
  • Movement Disorder Emergencies Diagnosis and Treatment, Second edition Humana Press (2013) ISBN 978-1-60761-834-8
  • O’Reardon, MD Clinical Manifestations, Diagnosis, and Empirical Treatments for Catatonia Psychiatry (Edgmont). 2007 Mar; 4(3): 46–52.
  • Movement disorder emergencies. J Neurol 2008;255 Suppl4:2-13.doi: 10.1007/s00415-008-4002-9
  • The differential diagnosis of catatonic states. A Psychosomatics. 1982 Mar; 23(3):245-52 doi: 10.1016/S0033-3182(82)73415-2