Transient Fever Response After ECT in a Patient with Catatonic Schizophrenia: A Case Report. / Katatonik Sizofreni Hastasinda EKT Sonrasi Ortaya Çikan Geçici Ates Yaniti: Olgu Sunumu.

Electroconvulsive therapy (ECT) is an effective and safe treatment method for many psychiatric disorders. In general medical practice, ECT may cause side effects as most other treatment methods do. Headache, myalgia, nausea, vomiting, confusion, anterograde amnesia are common side effects of electroconvulsive therapy. Fever; in addition to general medical conditions such as infection, malignancy, connective tissue diseases, drug treatments, malignant hyperthermia, convulsions, it can also occur due to conditions such as neuroleptic malignant syndrome (NMS), serotonin syndrome, catatonia, malignant catatonia, which are frequently encountered in psychiatry clinics. In the literature, transient fever response due to electroconvulsive therapy application have been described, albeit rarely. Although there are many proposed mechanisms for the emergence of a fever response, regardless of its cause, it is still not understood why some fever responses occur. In this article, we present the differential diagnosis of the fever response, possible causes, and the mechanisms that may reveal the secondary fever response to electroconvulsive therapy in a case with a diagnosis of catatonic schizophrenia, who developed a fever response during electroconvulsive therapy sessions and no fever response was observed at times other than electroconvulsive therapy sessions. In this case, postictal benign fever response associated with electroconvulsive therapy was considered after excluding other medical conditions that may cause a fever response after electroconvulsive therapy. Keywords: ECT, Fever, Catatonia, NMS.

Electroconvulsive Therapy-Resistant Catatonia: Case Report and Literature Review.

BACKGROUND: Untreated catatonia is associated with serious medical complications that can necessitate urgent medical attention. Lorazepam and electroconvulsive therapy (ECT) are effective for catatonia across various psychiatric or medical diagnoses. In rare cases, ECT fails to achieve full response in catatonic symptoms, particularly in patients with chronic catatonia or primary psychotic disorder. Evidence on treating catatonia that does not respond to ECT is lacking. OBJECTIVE: Conduct a literature review on treatment of ECT-resistant catatonia which is defined as that reported lack of full response to ECT treatments. We present a case of a 52-year-old male with schizophrenia where catatonia did not respond to lorazepam and robust ECT but resolved after memantine titration. METHODS: A literature review was performed using Medline/PubMed with the following keywords: treatment-resistant, catatonia, electroconvulsive therapy. References in eligible articles and most recent systematic reviews on catatonia treatment were reviewed. RESULTS: Seventeen patients in 12 case reports were identified where the treatment of catatonia was described after failed ECT trials. Most had chronic catatonia and a diagnosis of schizophrenia. ECT parameters and ictal outcome measures were not consistently reported. Treatment modalities for ECT-resistant catatonia included amantadine, memantine, lorazepam augmentation to ECT, and antiepileptic and antipsychotic medications such as aripiprazole and clozapine. CONCLUSIONS: The literature review and new case suggest reconsideration of catatonia diagnosis, optimizing ECT treatments, cautious use of antipsychotics, consideration of lorazepam augmentation to ECT treatments, and/or use of N-methyl-D-aspartate receptor antagonists.

Catatonic Schizophrenia Associated With Cerebrospinal GAD65 Autoantibodies: Case Report and Literature Review.

Background: GAD65 autoimmunity is reported to be associated with schizophrenia and bipolar disorder. However, there has been no evidence that glutamic acid decarboxylase 65 (GAD65) autoantibodies in cerebrospinal fluid (CSF) are associated with akinetic catatonia in schizophrenia patients. Methods: We report the case of a 28-year-old man who underwent diagnostics including brain MRI, neuropsychological testing, and electroencephalography (EEG) as well as a tumor search via CT of the abdomen and thorax, as well as colonoscopy and gastroscopy. For clinical characterization, his patient files were retrospectively examined. Results: Our patient presented catatonia that responded somewhat to benzodiazepines in combination with previously taken antipsychotics such as risperidone for prediagnosed paranoid schizophrenia. Diagnostics revealed GAD65 autoantibodies in his serum and CSF. MRI revealed no brain lesion, and the tumor search had no malignancy. We diagnosed catatonic schizophrenia. Furthermore, as he had not fully recovered, he was given immunotherapy entailing two cycles of intravenous immunoglobulins. Subsequent neuropsychological testing due to subjective cognitive complaints after immunotherapy revealed no objective cognitive deficits. Conclusions: We present the novel finding of an association between GAD65 autoantibodies in the serum and CSF with catatonia in a patient suffering from prediagnosed chronic schizophrenia. Due to the presence of CSF GAD65 antibodies and the catatonia factor in prediagnosed schizophrenia, we suspect that his catatonia has an autoimmune origin. Immunotherapy stabilized the catatonia that had initially responded to lorazepam treatment. Further research should be done to characterize patients' responses to immunotherapy and standard treatment in a large cohort of patients with GAD65 antibody-associated catatonia and schizophrenia.

Case Report: Successful Use of the Combination of Electroconvulsive Therapy and Clozapine in Treating Treatment-Resistant Schizophrenia and Catatonia in an Adult with Intellectual Disability.

There is paucity of empirical data regarding the use of either clozapine or electroconvulsive therapy (ECT) in the acute phase and maintenance treatment of schizophrenia in adults with intellectual disability. Herein we report the successful acute and long-term remission of psychotic symptoms and catatonia with the combination of clozapine and ECT in a 26-year-old female with moderate ID and treatment-resistant schizophrenia. To our knowledge, this is the first case example of the successful use of the combination of bilateral, standard-pulse ECT and clozapine in both acute and long-term treatment of treatment-resistant schizophrenia and catatonia in an adult with ID. Our report adds further support to the emerging evidence regarding the efficacy and safety of this combination in treatment-resistant schizophrenia.

Tratamiento del Síndrome Neuropsiquiátrico Diferido por intoxicación con monóxido de carbono con risperidona y oxígeno hiperbárico / Treatment of Delayed Post-Hypoxic Leukoencephalopathy as a complication of carbon monoxide poisoning with risperidone and hyperbaric oxygen therapy

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Treatment of Paroxysmal Perceptual Alteration in Catatonic Schizophrenia by Switching to Aripiprazole from Risperidone: A Case Report.

Paroxysmal perceptual alteration (PPA) is the occurrence of brief and recurrent episodes of perceptual changes. It is mainly caused by the treatment of schizophrenia patients with antipsychotics. However, diagnosis of PPA is not very prevalent among psychiatrists, partly due to underrecognition or misunderstanding that it is a worsening of psychiatric symptoms. If psychiatrists do not understand PPA, they cannot treat it appropriately, and the patient's quality of life is impaired. We present a case of PPA in catatonic schizophrenia that was successfully treated by switching to aripiprazole from risperidone. We suggest that the disappearance of PPA in our case was due to both discontinuing risperidone, which completely blocks D2 receptors, and replacing it with aripiprazole, which is characterized as a partial agonist of D2 receptors. Treatment of PPA will improve medication adherence and quality of life. It is important to recognize PPA as a possible side effect of treatment with antipsychotics.

Effectiveness of long-acting risperidone in a patient with comorbid intellectual disability, catatonic schizophrenia, and oneiroid syndrome.

A patient with comorbid intellectual disability, catatonic schizophrenia, and recurrent oneiroid state of consciousness improved on long-acting risperidone and remains well at the three-year follow-up. We report a case treated with 50 mg long-acting risperidone administered every 14 days, who has been followed-up for three years. We studied his regional cerebral blood flow through technetium-99 m hexamethylpropyleneamine oxime single-photon emission computed tomography after two years of treatment. Symptoms of catatonic schizophrenia improved after two months of treatment, followed suit by oneiroid syndrome remission. Two years later, his brain perfusion was normal. No side effect has occurred since the patient was started on long-acting risperidone. Long-acting risperidone proved to be safe and effective in treating symptoms of catatonia and oneiroid syndrome.

Successful use of right unilateral ECT for catatonia: a case series.

Catatonia is a neuropsychiatric syndrome involving motor signs in association with disorders of mood, behavior, or thought. Bitemporal electrode placement electroconvulsive therapy (ECT) is a proven effective treatment for catatonia, and this mode of ECT delivery is the preferred method of treatment in this condition. Studies in major depressive disorder have demonstrated that suprathreshold, nondominant (right) hemisphere, unilateral electrode placement ECT has fewer adverse effects, especially cognitive adverse effects, than bitemporal ECT. This case series describes the use of right unilateral (RUL) ECT in 5 patients with catatonia. Before ECT, all 5 patients in this series initially failed therapy with benzodiazepines and psychotropic medications. Each catatonic patient received a series of 8 to 12 RUL ECT in an every-other-day series. After ECT, 4 of the 5 patients had a full recovery from catatonia. One patient achieved only partial response to RUL ECT, and no additional benefit was obtained with bitemporal ECT. All patients in this case series tolerated RUL ECT without major adverse effects. This case series illustrates successful use of RUL ECT in patients with catatonia and adds to the early literature demonstrating its effective use in treating this complex condition.

Neuroleptic malignant syndrome masked by cerebral malaria.

A 38-year-old man with an underlying psychiatric illness presented with altered sensorium and abnormal behaviour. He was febrile at 38°C and weak looking; otherwise no other abnormalities were detected. A blood film conducted for malarial parasite (BFMP) revealed Plasmodium falciparum; hence a diagnosis of cerebral malaria was made. He was treated with antimalarial drugs for 2 days prior to being transferred out to the ward following clinical improvement. He subsequently developed episodes of stupor and refusal of feeding. Following an evaluation by the psychiatrist, a diagnosis of catatonic schizophrenia was made and he was started on oral sulpiride and benhexol. Unfortunately, he developed high-grade fever at 40°C with muscle rigidity and fasciculation. The diagnosis of neuroleptic malignant syndrome (NMS) was clinched and the antipsychotics were discontinued. However he succumbed to NMS several days later due to multiorgan failure.

[Hypothermia under olanzapine treatment: clinical case series and review of current literature]. / Hypothermie unter Olanzapin : Eine Fallserie mit Literaturübersicht.

BACKGROUND: Antipsychotic drugs may lead to hypothermia as well as hyperthermia. Although known for decades and clinically highly relevant, the mechanisms by which antipsychotic drugs alter thermoregulatory processes in the human body are still far from being fully understood. In clinical practice, much attention is paid to antipsychotic drug-induced elevation of body core temperature as observed in the neuroleptic malignant syndrome (NMS). But also hypothermia is a clinically highly relevant adverse reaction to antipsychotic drugs. MATERIAL AND METHODS: Here we report a case series of three patients who developed severe hypothermia after administration of olanzapine. A review of the current literature is given with a focus on risk factors for the development of antipsychotic drug-induced hypothermia and its pathophysiologic mechanisms. RESULTS: A 51-year-old female patient suffering from catatonic schizophrenia, cachectic nutritional condition and hypothyroidism developed severe hypothermia of 30.0°C body core temperature after administration of 30 mg olanzapine per day under comedication with lorazepam and L-thyroxine. A 48-year-old female patient with catatonic schizophrenia showed hypothermia of 31.0°C (rectal measurement) after single-dose administration of olanzapine 10 mg orally and a total of 3 mg lorazepam (1-1-1 mg). The third case report describes a 69-year-old male patient with acute delusional disorder exhibiting hypothermia of 33.0°C (rectal measurement) in combination with a reversible atrioventricular block grade III without any further comedication. CONCLUSION: A review of the current literature reveals that thermoregulatory disturbances as sequelae of antipsychotic drug administration depend on individual disposition as well as various independent risk factors such as environmental temperature, somatic comorbidities, endocrinological abnormalities (e.g. hypothyroidism) and structural damage of the brain. A complex interaction of dopaminergic regulatory mechanisms in the ventral hypothalamus and peripheral vaso- and sudomotor adjustments seems to be causative. Hypothermia following antipsychotic drug administration represents a serious adverse drug reaction and a potentially life-threatening event.

Physical deformity as sequela of chronic catatonia and response to electroconvulsive therapy: a case report.

Chronic catatonia with posturing can cause joint contractures leading to greater morbidity associated with the physical deformity. We report a case of a young man with chronic catatonic schizophrenia with posturing of bilateral upper limbs in flexion leading to fixed flexion contracture of left metacarpophalangeal joints. Initiation of electroconvulsive therapy along with physical rehabilitation measures helped him regain full range of motion in the right upper limb. The fixed flexion contracture, however, remained resistant to intensive treatment efforts. Early interventions in the form of electroconvulsive therapy and physical rehabilitation can be useful in reversing such potentially disabling complications.

[Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases].

Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases remain a topical problem in modem psychiatry. The author describes psychopathologcal features of oneiroid depending on the form of the affect and presents new data on its relation to peculiarities of the development of attacks.

Rocuronium antagonized by sugammadex for series of electroconvulsive therapy (ECT) in a patient with pseudocholinesterase deficiency.

We report the anesthetic management of a patient with catatonic schizophrenia and pseudocholinesterase deficiency, using the nondepolarizing neuromuscular blocking drug, rocuronium, reversed by its specific reversal agent, sugammadex, for a series of electroconvulsive therapy sessions. Rocuronium and sugammadex were used every 48 hours for 8 consecutive times and proved to be an effective and safe combination in a situation where succinylcholine was contraindicated.

[Dissolution of the wakefulness-sleep cycle in patients with catatonic form of schizophrenia].

Polysomnograms of two patients with catatonic form of schizophrenia of different duration of the disease were recorded and analyzed. Pronounced disorders of the wakefulness-sleep cycle (WSC) were revealed. Apart from differences connected with duration of the disease and treatment with corresponding medications, there were detected the general features indicating dissolution of the central nervous system and the very wakefulness-sleep cycle. A certain similarity of the found WSC disturbances with the earlier shown WSC disturbances in rats with predisposition to catalepsy was noted. The conclusion is made about domination of diencephalic influences over the telencephalic one in the studied patients.

Moderate clinical improvement with maintenance ECT in a 17-year-old boy with intractable catatonic schizophrenia.

The use of electro-convulsive therapy (ECT) in adolescents is controversial, and few studies have been conducted to assess its efficacy and safety in this population. We report the case of a 19-year-old boy who received two series of ECT, one at 15 and another at 16, for intractable catatonic schizophrenia. Since the age of 17, he has required treatment combining clozapine and maintenance ECT. The course showed a sustained moderate improvement. The treatment permitted the patient to regain some autonomy with moderate adverse effects. ECT remains an uncommon treatment in adolescents, and the current case supports the view that it should not be banned in young people.

Neuroleptic induced tardive dyskinesia in a patient on treatment for schizophrenia: case report.

In this case, a thirty six year old patient on treatment for schizophrenia is described with severe tardive dyskinesia. The most likely cause is long term treatment with two highly potent typical antipsychotic medications. The patient was initially treated with Benzhexol, an anticholinergic agent with the potential to induce or aggravate the disorder. This case discusses the common presentation and management of neuroleptic induced tardive dyskinesia.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia') III. Latent class analysis of the catatonic syndrome.

No reports have yet been published on catatonia using latent class analysis (LCA). This study applied LCA to a large, diagnostically homogenous sample of patients with chronic schizophrenia who also presented with catatonic symptoms. A random sample of 225 Chinese inpatients with DSM-IV schizophrenia was selected from the long-stay wards of a psychiatric hospital. Their psychopathology, extrapyramidal motor status and level of functioning were evaluated with standardized rating scales. Catatonia was rated using a modified version of the Bush-Francis Catatonia Rating Scale. LCA was then applied to the 178 patients who presented with at least one catatonic sign. In LCA a four-class solution was found to fit best the statistical model. Classes 1, 2, 3 and 4 constituted 18%, 39.4%, 20.1% and 22.5% of the whole catatonic sample, respectively. Class 1 included patients with symptoms of 'automatic' phenomena (automatic obedience, Mitgehen, waxy flexibility). Class 2 comprised patients with 'repetitive/echo' phenomena (perseveration, stereotypy, verbigeration, mannerisms and grimacing). Class 3 contained patients with symptoms of 'withdrawal' (immobility, mutism, posturing, staring and withdrawal). Class 4 consisted of 'agitated/resistive' patients, who displayed symptoms of excitement, impulsivity, negativism and combativeness. The symptom composition of these 4 classes was nearly identical with that of the four factors identified by factor analysis in the same cohort of subjects in an earlier study. In multivariate regression analysis, the 'withdrawn' class was associated with higher scores on the Scale of Assessment of Negative Symptoms and lower and higher scores for negative and positive items respectively on the Nurses' Observation Scale for Inpatient Evaluation's (NOSIE). The 'automatic' class was associated with lower values on the Simpson-Angus Extrapyramidal Side Effects Scale, and the 'repetitive/echo' class with higher scores on the NOSIE positive items. These results provide preliminary support for the notion that chronic schizophrenia patients with catatonic features can be classified into 4 distinct syndromal groups on the basis of their motor symptoms. Identifying distinct catatonic syndromes would help to find their biological substrates and to develop specific therapeutic measures.