New-onset organ dysfunction as a screening tool for the identification of sepsis and outcome prediction in dogs with systemic inflammation.

Introduction: Sepsis in people is defined as a life-threatening organ dysfunction (OD) caused by a dysregulated host response to infection. In veterinary medicine, sepsis is still defined by the presence of systemic inflammation plus the evidence of infection. Based on recent veterinary studies, multiorgan dysfunction syndrome (MODS) has been associated with a worse outcome in sepsis. Thus, the screening for OD is warranted to identify the most critically ill patients. The aim of this study was to investigate the diagnostic value of new-onset OD for the prediction of sepsis and outcome in a population of critically ill dogs with systemic inflammation. Materials and methods: Dogs admitted to the Emergency Room and/or the Intensive Care Unit with systemic inflammation, defined by a serum C-reactive protein concentration > 1.6 mg/dL, were retrospectively included. Enrolled dogs were categorized according to the presence of sepsis or non-infectious systemic inflammation. The presence of newly diagnosed OD was assessed based on criteria adapted from human literature and previously reported canine criteria. Results: 275 dogs were included: 128 had sepsis and 147 had non-infectious systemic inflammation. The frequency of new-onset OD was not different between these groups. Only the presence of fluid-refractory hypotension was significantly associated with a diagnosis of sepsis (OR 10.51, 3.08-35.94; p < 0.0001). The frequency of at least two ODs was significantly higher in non-survivors compared to survivors, according to both the human and the veterinary criteria considered for the study (p = 0.0001 and p = 0.0004, respectively). Specifically, the presence of acute kidney injury, stupor or coma, prolonged Prothrombin Time and decreased Base Excess were associated with a higher risk of death in the multivariate binary logistic regression. Discussion: In this population of critically ill dogs with systemic inflammation, the detection of newly diagnosed ODs was not able to predict sepsis diagnosis, other than the presence of fluid-refractory hypotension. However, given the strong prognostic significance associated with ODs, our results support the early screening for ODs in any severe inflammatory critical care condition to identify high-risk patients and optimize their management.

Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools.

BACKGROUND: Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients. AIM: The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients. METHOD: The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve. RESULTS: A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005). CONCLUSION: AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.

Rebound Catatonia Associated With Injectable Paliperidone.

Paliperidone is an atypical antipsychotic medication commonly used to treat schizophrenia, schizoaffective disorder, and bipolar disorder. It is a metabolite of risperidone and has a similar mechanism of action, primarily blocking dopamine 2 receptors (D2 receptors) in the brain. Paliperidone has various adverse effects, including extrapyramidal symptoms, weight gain, and metabolic disturbances. Catatonia is rare but severe side effects can occur in the context of an underlying psychiatric, neurologic, or general medical condition. Paradoxically, antipsychotics for treating schizophrenia or bipolar spectrum disorders can precipitate or worsen catatonic symptoms. The report suggests that 17-19% of all cases diagnosed as catatonia due to other medical conditions are medication-induced. Catatonia is a neuropsychiatric syndrome that presents as a cluster of psychomotor signs and symptoms resulting in movement and behavior aberrations. Various symptoms, including mutism, stupor, rigidity, and abnormal movements, characterize catatonia. Catatonia is a potentially life-threatening condition requiring prompt recognition and management. Here, we present a case of a patient with catatonia associated with long-acting injectable paliperidone intramuscular therapy in a patient with schizophrenia.

Aparente respuesta rápida a la combinación de zolpidem, memantina y aripiprazol en un caso de catatonía esquizofrénica / Apparent rapid response to the combination of zolpidem, memantine and aripiprazole in a case of schizophrenic catatonia

RESUMEN El tratamiento de la catatonía considera habitualmente el uso de benzodiacepinas y, de fallar estas, se procede a la terapia electroconvulsiva. Sin embargo, las hipotéticas vías neurobiológicas implicadas en la catatonía postulan un efecto benéfico de fármacos gabaérgicos y bloqueadores de glutamato. Se presenta el caso clínico de una paciente mujer de 45 años de edad, con diagnóstico de esquizofrenia paranoide, que desarrolló un cuadro de estupor catatónico (sin respuesta a las benzodiacepinas) y varias complicaciones médicas; sin embargo, el cuadro mejoró rápidamente con la combinación de zolpidem, memantina y aripiprazol. De este modo, se registró un desenlace no logrado con la terapia estándar de benzodiacepinas. Se concluye que la combinación de medicamentos gabaérgicos y bloqueadores de glutamato puede ser utilizada beneficiosamente en casos de estupor catatónico que no logran responder al manejo usual con benzodiacepinas.

ABSTRACT Objective: The treatment of catatonia usually involves the use of benzodiazepines and, if these fail, electroconvulsive therapy is applied. Nevertheless, hypothetical neurobiological pathways involved in catatonia postulate beneficial effects of GABAergic drugs and glutamate blockers. Clinical case: A 45-year-old female patient, diagnosed with paranoid schizophrenia who developed a catatonic stupor (with no response to benzodiazepines) and various medical complications; however, the condition improved rapidly with the combination of zolpidem, memantine and aripiprazole. Result: A favorable outcome was obtained in this case, not achieved with the previous use of standard benzodiazepine therapy. Conclusions: The combination of GABAergic drugs and glutamate blockers can be beneficially implemented in cases of catatonic stupor that fail to respond to the usual management with benzodiazepines.

Management of unanticipated difficult airway in a patient with well-visualized vocal cords using video laryngoscopy - A case report.

BACKGROUND: Difficult airway occurs due to anatomical abnormalities of the airway that can be predicted through airway assessments; however, abnormalities beyond the vocal cord can be clinically asymptomatic and undetected until intubation failure to advance the endotracheal tube. CASE: We present a case of an unanticipated difficult airway in a stuporous 80-year-old female with a recent history of intracerebral hemorrhage and prolonged intubation. She required emergency ventriculo-peritoneal shunt surgery due to the progression of her hydrocephalus. Under anesthesia, facemask ventilation was easy and video laryngoscopy provided a full view of the glottis; however, endotracheal tube (ETT) entry failed. We suspected stenosis beyond the vocal cord, and a smaller diameter ETT was inserted and maintained for airway management during emergency surgery. Postoperative neck computed tomography findings revealed laryngotracheal stenosis (LTS). CONCLUSIONS: Anesthesiologists should be aware that LTS may be asymptomatic and consider difficult airway guidelines in patients with history of prolonged endotracheal intubation.

Brain mechanisms underlying catatonia: A systematic review.

BACKGROUND: Catatonia is a complex psychomotor disorder characterized by motor, affective, and behavioral symptoms. Despite being known for almost 150 years, its pathomechanisms are still largely unknown. METHODS: A systematic research on PubMed, Web of Science, and Scopus was conducted to identify neuroimaging studies conducted on group or single individuals with catatonia. Overall, 33 studies employing structural magnetic resonance imaging (sMRI, n = 11), functional magnetic resonance imaging (fMRI, n = 10), sMRI and fMRI (n = 2), functional near-infrared spectroscopy (fNIRS, n = 1), single positron emission computer tomography (SPECT, n = 4), positron emission tomography (PET, n = 4), and magnetic resonance spectroscopy (MRS, n = 1), and 171 case reports were retrieved. RESULTS: Observational sMRI studies showed numerous brain changes in catatonia, including diffuse atrophy and signal hyperintensities, while case-control studies reported alterations in fronto-parietal and limbic regions, the thalamus, and the striatum. Task-based and resting-state fMRI studies found abnormalities located primarily in the orbitofrontal, medial prefrontal, motor cortices, cerebellum, and brainstem. Lastly, metabolic and perfusion changes were observed in the basal ganglia, prefrontal, and motor areas. Most of the case-report studies described widespread white matter lesions and frontal, temporal, or basal ganglia hypoperfusion. CONCLUSIONS: Catatonia is characterized by structural, functional, perfusion, and metabolic cortico-subcortical abnormalities. However, the majority of studies and case reports included in this systematic review are affected by considerable heterogeneity, both in terms of populations and neuroimaging techniques, which calls for a cautious interpretation. Further elucidation, through future neuroimaging research, could have great potential to improve the description of the neural motor and psychomotor mechanisms underlying catatonia.

Describing the features of catatonia: A comparative phenotypic analysis.

BACKGROUND: Catatonia is widely under-detected, and the many differences across catatonia rating scales and diagnostic criteria could be a key reason why clinicians have a hard time knowing what catatonia looks like and what constitutes each of its features. METHODS: This review begins by discussing the nature of catatonia diagnosis, its evolution in ICD and DSM, and different approaches to scoring. The central analysis then provides a descriptive survey of catatonia's individual signs across scales and diagnostic criteria. The goal of this survey is to characterize distinctions across scales and diagnostic criteria that can introduce variance into catatonia caseness. RESULTS: Diagnostic criteria for catatonia in DSM-5-TR and ICD-11 are broadly aligned in terms of which items are included, item definitions and number of items required for diagnosis; however, the lack of item thresholds is a fundamental limitation. Many distinctions across scales and criteria could contribute to diagnostic discordance. DISCUSSION: Clear, consistent definitions for catatonia features are essential for reliable detection. Of available scales, Bush-Francis and Northoff can be converted to diagnostic criteria with limited modification. Bush-Francis is the most efficient, with a screening instrument, videographic resources and standardized clinical assessment. Northoff offers the most detailed assessment and uniquely emphasizes emotional and volitional disturbances in catatonia. CONCLUSIONS: The field's understanding of the catatonia phenotype has advanced considerably over the past few decades. However, this review reveals many important limitations in the ICD and DSM as well as differences across scales and criteria that stand in the way of reliable catatonia detection.

Clinical features of catatonic non-convulsive status epilepticus: A systematic review of cases.

OBJECTIVE: Non-convulsive status epilepticus (NCSE) can manifest as catatonia, although it is unclear how frequently such cases have been reported. The common clinical features of these two conditions are also unclear. METHODS: Using the MEDLINE and Embase databases, we performed a systematic literature search to identify cases diagnosed with both catatonia, according to the Bush-Francis Catatonia Rating Scale, and NCSE, according to the Salzburg Consensus Criteria (last search: March 29, 2021). We extracted data on demographics, clinical features of catatonia, EEG findings, and treatments. RESULTS: A total of 66 patients with catatonic NSCE (men, 49%; mean age, 42.0 years) were identified from our search. Of the 66 cases described: 30 (46%) showed motor symptoms; 35 (38%) occurred in patients with preceding episodes of epileptic seizures; 19 (29%) showed subtle ictal clinical phenomena, such as minor twitching of the mouth, periorbital region, and extremities; 22 (33%) presented with psychiatric symptoms prior to the onset of catatonia; 17 (26%) had a history of psychiatric diseases; and in 10 cases (15%), NSCE was confirmed by intentional or non-intentional long-term EEG monitoring. Benzodiazepines were used as the initial treatment for NCSE in 30 cases (49%), of which 20 cases (73%) improved with monotherapy. DISCUSSION: A substantial number of cases included in the present review involved catatonia without any symptoms indicative of epilepsy, suggesting that NCSE may be misdiagnosed as a psychiatric disease, and highlighting the importance of the accurate diagnosis and treatment of NCSE in patients presenting with catatonia.

Síndrome catatónico en una adolescente gambiana: presentación de un caso inusual / Catatonic syndrome in a gambian teenager: an unusual case presentation

RESUMEN Fundamento: la catatonía es una de las presentaciones psiquiátricas más dramáticas, es muy rara en niños y adolescentes, por lo que puede ser mal diagnosticada al confundirse con cuadros psicóticos y provocar la muerte si no es tratada de manera adecuadada. Objetivo: presentar el caso inusual de una adolescente gambiana diagnosticada como un síndrome catatónico. Presentación del caso: adolescente de 14 años de edad, gambiana, femenina, fue ingresada en el Hospital Pediátrico de Banjul; debido a negarse a ingerir alimentos, agua y hablar por una semana. El examen físico reveló aumento de la frecuencia cardíaca, signos de deshidratación moderada, nivel de conciencia estuporoso y rigidez generalizada del cuerpo. Los estudios analíticos e fonomenológicos fueron normales. Se diagnosticó como un síndrome catatónico y luego de recibir tratamiento con lorazepam durante 10 días, fue dada de alta con evolución satisfactoria. Conclusiones: a pesar de ser la catatonía una rara afección, el médico general debe conocer esta enfermedad, con el fin de poner el tratamiento adecuado, para evitar su agravamiento y así preservar la vida de estos pacientes.

ABSTRACT Background: catatonia is one of the most dramatic psychiatric presentations, it is a very rare condition in children and adolescents, it could be misdiagnosed as a psychotic disorder, and could cause death if not treated properly. Objective: to discuss an unusual case of a Gambian female teenager diagnosed of catatonic syndrome. Case report: a 14-year-old Gambian female teenager was admitted to Banjul Pediatric Hospital because she refused to eat, drink or speak for one week. On physical examination she was found to have an increased heart rate, moderate signs of dehydration, stuporous level of consciousness and generalized rigidity of the body. The analytical and phonomenological studies were normal. After being diagnosed of catatonic syndrome and treated with Lorazepam for 10 days, she improved enough and she was satisfactorily discharged. Conclusions: despite the fact that catatonia is a rare condition, the general practitioner must know this pathology, in order to impose the appropriate treatment, avoid its aggravation and thus preserve the life of these patients.

Case Report: GABAergic and Serotoninergic Agents for the Treatment and Prevention of Prolonged Dissociative Stupor.

Dissociative stupor is a common psychiatric disease lacking an established standard treatment. The lack of therapeutic options may be due to the spontaneous and quick complete remission of most patients. However, since some patients experience multiple relapses and prolonged stupor, investigating potential prevention and treatment options is critical. We reported the case of a 61-year-old Japanese woman who presented with intermittent dissociative stupor for several months. Despite her prolonged symptoms, the administration of lorazepam, escitalopram, and aripiprazole, which selectively enhance GABAergic and serotoninergic activity, improved her stupor and prevented relapse. These findings may help with the treatment of persistent dissociative stupor.

THE TERMINAL APHONIA OF ALEXANDER THE GREAT, A SILENT HERALD OF AN ORDINARY DEATH

Even though the absence of the body prevents sure conclusions, the death of Alexander the Great remains a hot topic of retrospective diagnosis. Due to the serious mishandling of ancient sources, the scientific literature had Alexander dying of every possible natural cause. In previous works, the hypothesis that typhoid fever killed Alexander was proposed, based on the presence of the remittent fever typical of this disease in the narrations of Plutarch and Arrian. Here we provide additional evidence for the presence of stupor, the second distinctive symptom of typhoid fever. In fact, based on the authority of Caelius Aurelianus and Galen, we demonstrate that the word ἄφωνος, used to describe the last moments of Alexander, is a technical word of the lexicon of the pathology of Hippocrates. Used by him, the word defines a group of diseases sharing a serious depression of consciousness and motility. The association of stupor with the remittent fever strengthens the typhoid fever hypothesis.

Acute Disseminated Encephalomyelitis: Psychiatric Presentation of a Rare Diagnosis.

Acute disseminated encephalomyelitis (ADEM) is an autoimmune inflammatory disease of the central nervous system that is characterized by widespread demyelination, predominantly involving the white matter of the brain and spinal cord. Often caused by a viral infection or vaccination, its clinical features include an acute encephalopathy with multifocal neurologic signs and deficits in children. It can present with psychosis, depression, or abnormal behavior, and it might mimic a dissociative disorder. This report involves a similar rare case of a 14-year-old female patient who presented with fluctuating weakness of body, slurring of speech, tremor, loss of responsiveness, and abnormal behavior after her fever waned. Diagnosis of dissociative disorder was considered in the absence of neurological findings and ongoing significant stressor. Eventually, it turned out to be ADEM, which was confirmed by late neurological manifestations and radiological evaluation. Neuroimaging also revealed its differences from multiple sclerosis.

MECT combined with risperidone in the treatment of schizophrenia complicating 12-month stupor： a case report / 四川精神卫生

The report elaborated a case of a 52-year-old female patients with over 10 years of schizophrenia complicating 12 months of stupor. After a course of modified electroconvulsive therapy（MECT） combined with risperidone oral solution， the patient gradually became active and functionally recovered， and remained stable. This case suggests that MECT combined with risperidone may allow schizophrenia patients in a state of prolonged stupor to obtain clinical rehabilitation and effectively stabilize psychotic symptoms. The discussion is based on this case with a view to providing references for clinical treatment.

Case Report: Catatonic Stupor in Behavioral Variant Frontotemporal Dementia.

Catatonia is a psychomotor syndrome common to several medical and neuropsychiatric disorders. Here, we report on the case of a 95-year-old woman who underwent a radical change in personality characterized by sexual disinhibition, and physical and verbal aggressiveness. Over several months, she developed verbal stereotypies, gait deterioration, and double incontinence. She eventually developed mutism and an active opposition to all attempts to be fed or cared for. Benzodiazepines, olanzapine and electroconvulsive therapy were of no benefit. Magnetic resonance imaging revealed asymmetric (more severe on the right) frontotemporal, parietal, and upper brainstem atrophy. She died from sepsis without recovering from stupor seven years after the onset of symptoms. We believe that the initial behavioral disinhibition was related to the frontotemporal injury, whereas catatonic stupor reflected the progression of the degenerative process to the parietal cortices. Our case adds to the small number of cases of catatonia as a symptom of degenerative dementia. It also supports the idea that damage to the parietal cortex gives rise to pathological avoidance of which catatonic stupor represents an extreme form.

Differentiating Oneiric Stupor in Agrypnia Excitata From Dreaming Disorders.

Oneiric Stupor (OS) in Agrypnia Excitata represents a peculiar condition characterized by the recurrence of stereotyped gestures such as mimicking daily-life activities associated with the reporting of a dream mentation consisting in a single oneiric scene. It arises in the context of a completely disorganized sleep structure lacking any physiological cyclic organization, thus, going beyond the concept of abnormal dream. However, a proper differential diagnosis of OS, in the complex world of the "disorders of dreaming" can become quite challenging. The aim of this review is to provide useful clinical and videopolygraphic data on OS to differentiate it from other dreaming disorders. Each entity will be clinically evaluated among the areas of dream mentation and abnormal sleep behaviors and its polygraphic features will be analyzed and distinguished from OS.

Segmental Hair Testing of Triazolam to Unmask a Suspected Case of Idiopathic Recurrent Stupor.

ABSTRACT: Stupor is a diagnostic challenge at emergency department. Differential diagnosis includes idiopathic recurrent stupor, formerly attributed to "endozepine-4" accumulation. This condition has been recently questioned because many suspected cases resulted in exogenous benzodiazepine intake that eludes the conventional toxicological assay. In case of unexplained recurrent stupor, to extend the benzodiazepine search in nonconventional matrices can allow unmasking of hidden toxic behavior.

A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy.

BACKGROUND: Ritualistic behaviors are common in obsessive compulsive disorder (OCD), while catatonic stupor occasionally occurs in psychotic or mood disorders. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms. The syndrome usually represents a specific diagnosis, as in the case of the 10th edition of the International Classification of Diseases (ICD-10) or the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, symptom-based diagnosis can result in misdiagnosis and hinder effective treatment. Few cases of ritualistic behaviors and catatonic stupor associated with schizoaffective disorder have been reported. Risperidone and modified electroconvulsive therapy (MECT) were effective in our case. CASE PRESENTATION: A 35-year-old man with schizoaffective disorder-depression was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled us to make the diagnosis of OCD. Sertraline add-on treatment exacerbated the psychotic symptoms, such as pressure of thoughts and delusion of control. In the presence of obvious psychotic symptoms and depression, schizoaffective disorder-depression was diagnosed according to ICD-10. Meanwhile, the patient unfortunately developed catatonic stupor and respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone were administered. As a result, we successfully cured the patient with the abovementioned treatment strategies. Eventually, the patient was diagnosed with schizoaffective disorder-depression with ritualistic behaviors and catatonia. Risperidone and MECT therapies were dramatically effective. CONCLUSION: Making a differential diagnosis of mental disorders is a key step in treating disease. Sertraline was not recommended for treating schizoaffective disorder-depression according to our case because it could exacerbate positive symptoms. Controversy remains about whether antipsychotics should be administered for catatonic stupor. However, more case studies will be needed. Risperidone with MECT was beneficial for the patient in our case.

Does persisting fear sustain catatonia?

OBJECTIVE: To examine the psychological substrate of catatonia. METHOD: Reviewing the historical descriptions and explanations of catatonic behaviours by clinicians from its delineation in the 19th century to the present. RESULTS: Patients with catatonia are often haunted by fears and terrors; this has not been widely appreciated, and certainly was lost from view in the days when catatonia was considered a subtype of schizophrenia. The report contributes to resolving a major question in catatonia: is the mind in stupor inactive, as the blank state that we picture in anesthetized patients, or is the mind active, so preoccupied as to exclude all other influences. THE MAIN FINDING: Persistent fear occupies the mind of catatonic patients. CONCLUSION: The signs of catatonia are adaptations to persistent fear, akin to tonic immobilization. The relief afforded by sedation supports this interpretation.