ABSTRACT
BACKGROUND: Catatonia is a rare neuropsychiatric condition; it is estimated that around 10% of patients with mood disorders present signs and symptoms of catatonia. A catatonic syndrome is characterised by mutism, negativism, rigidity, and stupor. CASE REPORT: We report the case of a 59-year-old patient with a medical history of bipolar disorder who was admitted to the internal medicine service due to a seizure episode. During hospitalisation, the patient presented significant worsening of her clinical condition, showing marked symptoms of stupor and catatonia. Once the neurological and metabolic etiologies of altered mental status had been ruled out, pharmacological treatment with high doses of lorazepam was started. The patient had a complete clinical remission, and her evolution was favourable without any complications. Electroconvulsive therapy was recommended as a definitive treatment. CONCLUSIONS: The diagnosis of catatonia is a challenge for both hospitalists and psychiatrists due to the clinical presentation of catatonia. In reporting this clinical case, we want to emphasise the importance of taking into account the catatonic syndrome in our differential diagnoses in patients with altered mental status.
Subject(s)
Bipolar Disorder , Catatonia , Electroconvulsive Therapy , Lorazepam , Humans , Catatonia/diagnosis , Catatonia/drug therapy , Catatonia/etiology , Catatonia/therapy , Female , Middle Aged , Diagnosis, Differential , Lorazepam/administration & dosage , Lorazepam/therapeutic use , Bipolar Disorder/diagnosis , Bipolar Disorder/drug therapy , Electroconvulsive Therapy/methods , Stupor/diagnosis , Stupor/etiology , Seizures/diagnosis , Seizures/etiology , Seizures/drug therapyABSTRACT
PURPOSE: Divers can experience cognitive impairment due to inert gas narcosis (IGN) at depth. Brain-derived neurotrophic factor (BDNF) rules neuronal connectivity/metabolism to maintain cognitive function and protect tissues against oxidative stress (OxS). Dopamine and glutamate enhance BDNF bioavailability. Thus, we hypothesized that lower circulating BDNF levels (via lessened dopamine and/or glutamate release) underpin IGN in divers, while testing if BDNF loss is associated with increased OxS. METHODS: To mimic IGN, we administered a deep narcosis test via a dry dive test (DDT) at 48 msw in a multiplace hyperbaric chamber to six well-trained divers. We collected: (1) saliva samples before DDT (T0), 25 msw (descending, T1), 48 msw (depth, T2), 25 msw (ascending, T3), 10 min after decompression (T4) to dopamine and/or reactive oxygen species (ROS) levels; (2) blood and urine samples at T0 and T4 for OxS too. We administered cognitive tests at T0, T2, and re-evaluated the divers at T4. RESULTS: At 48 msw, all subjects experienced IGN, as revealed by the cognitive test failure. Dopamine and total antioxidant capacity (TAC) reached a nadir at T2 when ROS emission was maximal. At decompression (T4), a marked drop of BDNF/glutamate content was evidenced, coinciding with a persisting decline in dopamine and cognitive capacity. CONCLUSIONS: Divers encounter IGN at - 48 msw, exhibiting a marked loss in circulating dopamine levels, likely accounting for BDNF-dependent impairment of mental capacity and heightened OxS. The decline in dopamine and BDNF appears to persist at decompression; thus, boosting dopamine/BDNF signaling via pharmacological or other intervention types might attenuate IGN in deep dives.
Subject(s)
Cognitive Dysfunction , Diving , Inert Gas Narcosis , Stupor , Humans , Brain-Derived Neurotrophic Factor/metabolism , Cognitive Dysfunction/etiology , Decompression/adverse effects , Diving/adverse effects , Dopamine/metabolism , Glutamates , Inert Gas Narcosis/complications , Reactive Oxygen Species , Stupor/etiologyABSTRACT
BACKGROUND: The occurrence of large-vessel occlusion in young patients with coronavirus disease 2019 (COVID-19) infection has been exceedingly rare. An extensive review of reported studies revealed a few reported cases. In the present report, we have described the clinical presentation, radiological findings, and outcome of large-vessel occlusion in a young patient with COVID-19 and reviewed the pertinent reported data on this condition. CASE DESCRIPTION: A 31-year-old woman was in her usual state of health until she had presented with a 3-day history of right-sided weakness, slurred speech, and decreased vision. The patient had been taken to several hospitals where she had been treated conservatively with analgesics and discharged. Shortly thereafter, her weakness had become progressive. She had become severely dysarthric and unresponsive. On arrival to the emergency department, her physical examination revealed that she was stuporous, with a Glasgow coma scale of 10 (eye response, 3; verbal response, 2; motor response, 5). The National Institutes of Health Stroke Scale score was 19 on presentation. Brain computed tomography and computed tomography venography revealed an occluded left internal carotid artery and left middle cerebral artery with subacute left middle cerebral artery territory infarction and midline shift. Computed tomography angiography revealed complete occlusion of the left common carotid artery. An emergent decompressive craniectomy was successfully performed. The patient was shifted to the intensive care unit. She was later found to be positive for COVID-19. CONCLUSIONS: Although rare, patients with COVID-19 can present with large-vessel occlusion. Prompt identification of COVID-19-related coagulopathy is essential to assess young patients with clinical manifestations of infarction.
Subject(s)
COVID-19/complications , Carotid Artery Thrombosis/etiology , Infarction, Middle Cerebral Artery/etiology , Adult , COVID-19/diagnosis , Carotid Artery Thrombosis/diagnostic imaging , Carotid Artery Thrombosis/surgery , Carotid Artery, Common , Computed Tomography Angiography , Decompressive Craniectomy , Dysarthria/etiology , Epilepsy/complications , Female , Hemiplegia/etiology , Humans , Hypertension/complications , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/surgery , Stupor/etiology , Tomography, X-Ray ComputedABSTRACT
Tracheal stenosis is an uncommon but severe problem after long-term intubation. Here, we report a patient who came from a containment zone of coronavirus disease 2019 (COVID-19) and presented with complaints of breathlessness and cough. She was suspected to have an infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Later, she developed type 2 respiratory failure and carbon dioxide narcosis because of delay in diagnosis of severe, near-complete postintubation tracheal stenosis due to over suspicion of COVID-19 during the current pandemic.
Subject(s)
Betacoronavirus/pathogenicity , Clinical Laboratory Techniques , Coronavirus Infections/diagnosis , Diagnostic Errors , Intubation, Intratracheal/adverse effects , Pneumonia, Viral/diagnosis , Tomography, X-Ray Computed , Tracheal Stenosis/diagnostic imaging , Adult , COVID-19 , COVID-19 Testing , Coronavirus Infections/therapy , Coronavirus Infections/virology , Delayed Diagnosis , Female , Humans , Pandemics , Pneumonia, Viral/therapy , Pneumonia, Viral/virology , Predictive Value of Tests , Respiratory Insufficiency/etiology , SARS-CoV-2 , Stupor/etiology , Tracheal Stenosis/etiology , Tracheal Stenosis/therapySubject(s)
Arteriovenous Fistula/diagnosis , Dura Mater/blood supply , Intracranial Arteriovenous Malformations/diagnosis , Arteriovenous Fistula/complications , Clinical Decision-Making , Gastroenteritis/diagnosis , Gastroenteritis/etiology , Humans , Intracranial Arteriovenous Malformations/complications , Male , Middle Aged , Quadriplegia/diagnosis , Quadriplegia/etiology , Stupor/diagnosis , Stupor/etiologySubject(s)
Analgesics, Opioid/toxicity , Body Packing/statistics & numerical data , Rupture/complications , Stupor/etiology , Body Packing/trends , Female , Foreign Bodies/diagnostic imaging , Foreign Bodies/surgery , Humans , Middle Aged , Severity of Illness Index , Tomography, X-Ray Computed/methods , Treatment OutcomeSubject(s)
Acidosis, Respiratory/etiology , Atrial Fibrillation/surgery , Bundle-Branch Block/etiology , Carbon Dioxide/blood , Catheter Ablation , Conscious Sedation/adverse effects , Stupor/etiology , Acidosis, Respiratory/blood , Acidosis, Respiratory/diagnosis , Acidosis, Respiratory/therapy , Action Potentials , Adult , Atrial Fibrillation/diagnosis , Atrial Fibrillation/physiopathology , Bundle-Branch Block/diagnosis , Bundle-Branch Block/physiopathology , Electrocardiography , Heart Rate , Humans , Male , Risk Factors , Severity of Illness Index , Stupor/blood , Stupor/diagnosis , Stupor/therapy , Treatment OutcomeABSTRACT
BACKGROUND: Abnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention. METHODS: We identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging. RESULTS: Between two institutions, we identified six patients-ages 33-59 years, four male-with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up. CONCLUSIONS: We present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.
Subject(s)
Basal Ganglia/diagnostic imaging , Benzodiazepines/adverse effects , Brain Edema/diagnostic imaging , Central Nervous System Stimulants/adverse effects , Cerebellar Cortex/diagnostic imaging , Hippocampus/diagnostic imaging , Hydrocephalus/diagnostic imaging , Opiate Alkaloids/adverse effects , Adult , Alcoholic Intoxication/complications , Amphetamines/adverse effects , Brain Edema/chemically induced , Brain Edema/physiopathology , Brain Edema/therapy , Cerebellum/diagnostic imaging , Cocaine/adverse effects , Coma/etiology , Female , Heroin/adverse effects , Humans , Hydrocephalus/etiology , Hydrocephalus/physiopathology , Hydrocephalus/therapy , Hydromorphone/adverse effects , Magnetic Resonance Imaging , Male , Middle Aged , Pain, Postoperative/drug therapy , Stupor/etiology , Substance-Related Disorders , SyndromeABSTRACT
In this study, we evaluate the role of the thalamus in the neural circuitry of arousal. Level of consciousness within the first 12 hours of a thalamic stroke is assessed with lesion symptom mapping. Impaired arousal correlates with lesions in the paramedian posterior thalamus near the centromedian and parafascicular nuclei, posterior hypothalamus, and midbrain tegmentum. All patients with severely impaired arousal (coma, stupor) had lesion extension into the midbrain and/or pontine tegmentum, whereas purely thalamic lesions did not severely impair arousal. These results are consistent with growing evidence that pathways most critical for human arousal lie outside the thalamus. Ann Neurol 2018;84:926-930.
Subject(s)
Brain Stem/pathology , Coma/etiology , Stroke/complications , Stroke/pathology , Stupor/etiology , Thalamus/pathology , Arousal/physiology , Brain Mapping , Coma/diagnostic imaging , Female , Humans , Imaging, Three-Dimensional , Magnetic Resonance Imaging , Male , Retrospective Studies , Stroke/diagnostic imaging , Stupor/diagnostic imaging , Thalamus/diagnostic imaging , Time FactorsSubject(s)
Benzodiazepines/pharmacology , Catatonia/drug therapy , Drug Tolerance , Intellectual Disability , Lorazepam/pharmacology , Stupor/drug therapy , Benzodiazepines/administration & dosage , Catatonia/etiology , Humans , Intellectual Disability/complications , Lorazepam/administration & dosage , Male , Middle Aged , Stupor/etiology , Treatment RefusalABSTRACT
BACKGROUND: Neurological complications in liver failure are common. Often under-recognized neurological complications are seizures and status epilepticus. These may go unrecognized without continuous electroencephalography (CEEG). We highlight the observed electro-radiological changes in patients with grade III/IV hepatic encephalopathy (HE) found to have seizures and/or status epilepticus on CEEG and the associated neuroimaging. METHODS: This study was a retrospective review of patients with West Haven grade III/IV HE and seizures/status epilepticus on CEEG. RESULTS: Eleven patients were included. Alcohol was the most common cause of HE (54.5%). All patients were either stuporous/comatose. The most common CEEG pattern was diffuse slowing (100%) followed by generalized periodic discharges (GPDs; 36.4%) and lateralized periodic discharges (LPDs, 36.4%). The subtype of GPDs with triphasic morphology was only seen in 27.3%. All seizures and/or status epilepticus were without clinical signs. Magnetic resonance imaging (MRI) was available in six patients. Cortical hyperintensities on diffusion weighted imaging sequence were seen in all six patients. One patient had CEEG seizure concomitantly with the MRI. Seven patients died prior to discharge. CONCLUSION: Seizures or status epilepticus in the setting of HE were without clinical findings and could go unrecognized without CEEG. The finding of cortical hyperintensity on MRI should lead to further evaluation for unrecognized seizure or status epilepticus.
Subject(s)
Coma/physiopathology , Hepatic Encephalopathy/physiopathology , Liver Failure/complications , Seizures/physiopathology , Stupor/physiopathology , Adult , Aged , Coma/diagnostic imaging , Coma/etiology , Electroencephalography , Female , Hepatic Encephalopathy/diagnostic imaging , Hepatic Encephalopathy/etiology , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Retrospective Studies , Seizures/diagnosis , Seizures/etiology , Status Epilepticus/diagnostic imaging , Status Epilepticus/etiology , Status Epilepticus/physiopathology , Stupor/diagnostic imaging , Stupor/etiologyABSTRACT
Stupor and coma are clinical states in which patients have impaired responsiveness or are unresponsive to external stimulation and are either difficult to arouse or are unarousable. The term stupor refer to states between alertness and coma. An alteration in arousal represents an acute life-threatening emergency, requiring prompt intervention for preservation of life and brain function.
Subject(s)
Consciousness Disorders/diagnosis , Consciousness Disorders/therapy , Emergencies , Arousal , Coma/classification , Coma/diagnosis , Coma/etiology , Coma/therapy , Consciousness Disorders/classification , Consciousness Disorders/etiology , Diagnosis, Differential , Disorders of Excessive Somnolence/classification , Disorders of Excessive Somnolence/diagnosis , Disorders of Excessive Somnolence/etiology , Glasgow Coma Scale , Humans , Interdisciplinary Communication , Intersectoral Collaboration , Neurologic Examination , Prognosis , Stupor/classification , Stupor/diagnosis , Stupor/etiology , Stupor/therapy , Unconsciousness/classification , Unconsciousness/diagnosis , Unconsciousness/etiology , Unconsciousness/therapyABSTRACT
BACKGROUND AND AIMS: We performed a prospective multi-national study of patients presenting to the emergency department with upper GI bleeding (UGIB) and assessed the relationship of time to presentation after onset of UGIB symptoms with patient characteristics and outcomes. METHODS: Consecutive patients presenting with overt UGIB (red-blood emesis, coffee-ground emesis, and/or melena) from March 2014 to March 2015 at 6 hospitals were included. Multiple predefined patient characteristics and outcomes were collected. Rapid presentation was defined as ≤6 hours. RESULTS: Among 2944 patients, 1068 (36%) presented within 6 hours and 576 (20%) beyond 48 hours. Significant independent factors associated with presentation ≤6 hours versus >6 hours on logistic regression included melena (odds ratio [OR], 0.22; 95% CI, 0.18-0.28), hemoglobin ≤80 g/L (OR, 0.47; 95% CI, 0.36-0.61), altered mental status (OR, 2.06; 95% CI, 1.55-2.73), albumin ≤30 g/L (OR, 1.43; 95% CI, 1.14-1.78), and red-blood emesis (OR, 1.29; 95% CI, 1.06-1.59). Patients presenting ≤6 hours versus >6 hours required transfusion less often (286 [27%] vs 791 [42%]; difference, -15%; 95% CI, -19% to -12%) because of a smaller proportion with low hemoglobin levels, but were similar with regard to hemostatic intervention (189 [18%] vs 371 [20%]), 30-day mortality (80 [7%] vs 121 [6%]), and hospital days (5.0 ± 0.2 vs 5.0 ± 0.2). CONCLUSIONS: Patients with melena alone delay their presentation to the hospital. A delayed presentation is associated with a decreased hemoglobin level and increases the likelihood of transfusion. Other outcomes are similar with rapid versus delayed presentation. Time to presentation should not be used as an indicator for poor outcome. Patients with delayed presentation should be managed with the same degree of care as those with rapid presentation.
Subject(s)
Duodenal Diseases/blood , Esophageal Diseases/blood , Hematemesis/blood , Melena/blood , Patient Acceptance of Health Care/statistics & numerical data , Stomach Diseases/blood , Aged , Blood Transfusion/statistics & numerical data , Confusion/etiology , Duodenal Diseases/mortality , Duodenal Diseases/therapy , Esophageal Diseases/mortality , Esophageal Diseases/therapy , Female , Glasgow Coma Scale , Hematemesis/mortality , Hematemesis/therapy , Hemoglobins/metabolism , Hemostasis, Endoscopic/statistics & numerical data , Humans , Length of Stay/statistics & numerical data , Lethargy/etiology , Male , Melena/mortality , Melena/therapy , Middle Aged , Prognosis , Prospective Studies , Serum Albumin/metabolism , Stomach Diseases/mortality , Stomach Diseases/therapy , Stupor/etiology , Time-to-TreatmentSubject(s)
Polycythemia/complications , Pulmonary Disease, Chronic Obstructive/complications , Stupor/etiology , Subarachnoid Hemorrhage/etiology , Aged , Brain/diagnostic imaging , Humans , Male , Polycythemia/diagnostic imaging , Pulmonary Disease, Chronic Obstructive/diagnostic imaging , Stupor/diagnostic imaging , Subarachnoid Hemorrhage/diagnostic imaging , Tomography, X-Ray ComputedABSTRACT
Neurological complications of haemolytic uraemic syndrome (HUS) include altered states of consciousness, seizures, ischaemic stroke and encephalopathy. Adult-onset HUS is uncommon, and there is only a limited literature reporting neurological complications in this population. We report an adult with Shiga toxin-associated HUS complicated by focal-onset non-convulsive status epilepticus, who made a full neurological recovery.
Subject(s)
Escherichia coli Infections/diagnosis , Foodborne Diseases/diagnosis , Hemolytic-Uremic Syndrome/diagnosis , Meat/microbiology , Seizures/diagnosis , Stupor/diagnosis , Animals , Escherichia coli/isolation & purification , Escherichia coli Infections/complications , Escherichia coli Infections/therapy , Female , Foodborne Diseases/etiology , Foodborne Diseases/therapy , Hemolytic-Uremic Syndrome/etiology , Hemolytic-Uremic Syndrome/therapy , Humans , Meat/adverse effects , Middle Aged , Seizures/etiology , Seizures/therapy , Shiga Toxin/isolation & purification , Stupor/etiology , Stupor/therapy , SwineABSTRACT
We present a 46-year-old woman with a relapse of multiple sclerosis (MS) that began 3 months after withdrawal from long-term treatment with natalizumab. Shortly after restart of a single dose of natalizumab she developed a fulminant MS rebound with stupor and tetraparesis. Cerebral MRI showed massive progression in the number of lesions and tumefactive lesions with ring gadolinium-enhancement. Stereotactic brain biopsy revealed acute demyelination and B-cell dominated inflammation. The patient improved during therapeutic plasma exchange. We speculate that early restart of natalizumab in the case of a relapse may worsen disease evolution possibly by modifying regulatory immune effector processes during an inflammatory rebound phase. A restart of natalizumab in MS patients suffering from a recent relapse or with signs of active inflammation should be considered with caution.
Subject(s)
Multiple Sclerosis, Relapsing-Remitting/complications , Multiple Sclerosis, Relapsing-Remitting/drug therapy , Natalizumab/therapeutic use , Substance Withdrawal Syndrome/drug therapy , Substance Withdrawal Syndrome/physiopathology , B-Lymphocytes/immunology , B-Lymphocytes/pathology , Demyelinating Diseases/etiology , Demyelinating Diseases/pathology , Female , Humans , Inflammation/pathology , Magnetic Resonance Imaging , Middle Aged , Paralysis/etiology , Plasma Exchange , Recurrence , Stereotaxic Techniques , Stupor/etiology , Substance Withdrawal Syndrome/psychologyABSTRACT
An elderly woman diagnosed with multiple myeloma (MM) in 2007 had improved with chemotherapy. She had severe kyphosis and a diaphragmatic hernia (DH), but no respiratory symptoms. In 2011, because of thoracic deformity and emaciation, we advised her to continue the previously prescribed domiciliary noninvasive positive pressure ventilation (NPPV) therapy for chronic type II respiratory failure. However, she refused to continue NPPV. She was later admitted for deterioration in respiratory status and carbon dioxide (CO2) narcosis. We believed her low adherence to domiciliary NPPV caused CO2 narcosis; hence, we advised her to continue domiciliary NPPV and she complied. In May 2012, the now 79-year-old patient was admitted for acute exacerbation of chronic respiratory failure and CO2 narcosis. Chest imaging suggested that DH had caused a deterioration of her status. She underwent laparoscopic diaphragmatic hernia repair. Operative findings revealed a retrosternal hernia sac, and she was diagnosed as having a Morgagni hernia (MH). Her respiratory status subsequently improved. We hypothesize that NPPV increased intra-abdominal pressure, thereby worsening the MH and exacerbating respiratory failure. We believe that clinicians should be cautious when prescribing NPPV for MH patients.
Subject(s)
Hernias, Diaphragmatic, Congenital/etiology , Noninvasive Ventilation/adverse effects , Positive-Pressure Respiration/adverse effects , Respiratory Insufficiency/etiology , Aged , Aged, 80 and over , Chronic Disease , Disease Progression , Female , Hernias, Diaphragmatic, Congenital/surgery , Herniorrhaphy , Humans , Laparoscopy , Male , Respiratory Insufficiency/therapy , Stupor/etiologyABSTRACT
AIM: to determine the role of serum lactate and diabetic ketoacidosis (DKA) severity as predictors for five-days mortality in DKA patients. METHODS: a prospective cohort study was conducted in DKA patients admitted to emergency department (ED) at Cipto Mangunkusumo Hospital, Jakarta, Indonesia, during 2007-2008 periods. Predictors for 5 days mortality in DKA patients in this study including serum lactate and DKA severity (plasma glucose, arterial blood pH, serum bicarbonate, osmolality, anion gap, and alteration in sensorium) at admission. Cox's Proportional Hazard Regression Analysis was used to determine independent predictors for 5-days mortality among study population. RESULTS: sixty patients with diabetic ketoacidosis were enrolled in the study; in which 24 (40%) patients were died within 5 days after admission. In the multivariate analysis, the lactate level 4 mmol/L (HR, 3.09; 95% CI, 1.36-7.05) and altered in sensorium stuporous/comatose (HR, 3.38; 95% CI, 1.45-7.87) were identified as independent predictors for 5-days mortality in DKA adult patients. CONCLUSION: lactate level 4 mmol/L and altered in sensorium stuporous/comatose can be used to predict 5-days mortality in adult patients with DKA.
Subject(s)
Diabetic Ketoacidosis/blood , Diabetic Ketoacidosis/mortality , Lactic Acid/blood , Sepsis/mortality , Severity of Illness Index , Acid-Base Equilibrium , Adult , Aged , Bicarbonates/blood , Blood Glucose/metabolism , Coma/etiology , Diabetic Ketoacidosis/complications , Female , Humans , Male , Middle Aged , Osmolar Concentration , Proportional Hazards Models , Prospective Studies , Risk Factors , Sepsis/blood , Sepsis/complications , Stupor/etiology , Time FactorsABSTRACT
Catatonia was first described by a German psychiatrist, Karl Kahlbaum, in 1874. It is a behavioral syndrome marked by an inability to move normally, which can occur in the context of many underlying general medical and psychiatric disorders. A wide variety of neurologic, metabolic, drug-induced, and psychiatric causes of catatonia have been reported. We present a unique case of late onset catatonia in a 56-year-old man with no prior medical or psychiatric history initially presenting with stroke-like symptoms. The patient was awake and alert, with spontaneous eye opening, but completely nonverbal and not following any commands. Specifically, the patient demonstrated stupor, catalepsy, mutism, and negativism. After extensive emergency department testing, including negative computed tomography head, negative magnetic resonance imaging brain, negative electroencephalogram, and normal laboratory results, the patient was diagnosed with new-onset bipolar disorder with depressive features presenting as catatonia. Recognizing catatonia is important because it may be caused or exacerbated by treatment of the underlying disorder. Failure to institute treatment early in the course of catatonia is associated with a poor prognosis.