Catatonia as an Etiology of Persistent Altered Mental Status in a Critically Ill Pediatric Patient

First Author(s)

• 

  Robert Ohman, MD, MPH

  University of Washington
  Seattle, Washington

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• CA

  Christie Atchison, MD

  Critical Care Medicine Fellow
  Seattle Children's Hospital, United States

  Disclosure information not submitted.
• 

  Elizabeth Killien, MD, MPH

  Assistant Professor
  Seattle Children's Hospital
  Seattle, Washington

  Disclosure information not submitted.

Title: Catatonia as an etiology of persistent altered mental status in a critically ill pediatric patient.

Case Report Body:

Introduction: Altered mental status (AMS) commonly develops in critically ill children during their ICU stay. After ruling out organic causes of encephalopathy, management is typically focused on avoidance of deliriogenic drugs, including benzodiazepines. We present a case demonstrating that catatonia is a rare but important etiology in the differential, with implications for medical management and high risk of morbidity and mortality.

Description: A 17-year-old male with Duchenne muscular dystrophy was admitted to the ICU for management of necrotizing soft tissue infection of the perineum, with a protracted course complicated by peritonitis and necrotizing pancreatitis. He initially communicated non-verbally with providers and followed commands despite mechanical ventilation. On day 37, he demonstrated upward eye deviation and decreased responsiveness to stimuli, with continued decline in mental status from prior baseline with no interactivity with his environment by day 40. Workup, including continuous EEG, MRI, CT, and screening for metabolic causes of encephalopathy, was unrevealing, and his mental status continued to decline despite weaning sedative medications. Olanzapine was started for hypoactive delirium on day 43. During this time, he developed autonomic changes with episodes of tachycardia, tachypnea, and hypertension. On day 50, a lorazepam challenge to evaluate for malignant catatonia was performed, and within 2 minutes of administration he opened his eyes, moved spontaneously, and followed commands before again becoming obtunded. This effect was reproducible with additional lorazepam doses. He was initiated on daily lorazepam and antipsychotic medications were discontinued. Within 3 days his mental status returned to baseline and his autonomic instability resolved. He was able to interact with family and bedside providers and engage in discussions around his goals of care.

Discussion: Catatonia is a rare cause of AMS in the ICU with management centered on benzodiazepine administration and avoidance of antipsychotics, contrary to typical methods seeking to minimize delirium. Malignant catatonia includes features of hyperthermia and autonomic instability and is associated with morbidity and mortality. Catatonia should be considered when AMS is prolonged and not responding to typical interventions.