Table of Contents - Academy of Psychosomatic Medicine

months later, she was readmitted for recurrent confusion, insomnia,
paranoia, and difficulty expressing herself. She was
not in Addisonian crisis, CSF and MRI studies were normal,
and paraneoplastic antibodies were negative. Her TSH was
low, felt to be from overcorrected hypothyroidism. She was
given pulse dose steroids for 3 days, with rapid taper down
to physiologic doses when anti-thyroid antibodies were not
elevated. As the steroids were tapered down, she developed
catatonic signs including echopraxia, gegenhalten, ambitendency,
and automatic obedience. Catatonic signs did not
respond to high dose Ativan (up to 28 mg/day). The patient
was transferred to inpatient psychiatry, received 11 treatments
of ECT, and made a near complete recovery.
Conclusion: This case illustrates the complex neuropsychiatric
manifestations of autoimmune disease. We hypothesize
our patient’s encephalopathy, and later catatonia, resulted
from a combination of her autoimmune illnesses, and too
rapid of a steroid taper. She responded well to electroconvulsive
therapy, although more aggressive use of steroids
may have been warranted as well.
References:
1) Anglin RE, Rosebush PI, Mazurek MF: The Neuropsychiatric
Profile of Addison’s Disease: Revisiting a Forgotten
Phenomenon. J Neuropsychiatry Clin Neurosci 2006;
18(4):450-459.
2) Barnes MP et al.: The syndrome of Karl Ludwig Kahlbaum.
Journal of Neurology, Neurosurgery, and Psychiatry
1986; 49:991-996.
3) Castillo et al.: SREAT. Arch Neurol 2006; 63:197-202.
46. Catatonia Related to Ventriculomegaly
in an Adolescent Mennonite Male - A Case
Presentation, Literature Review, and Cultural
Discussion
Presenting Author: Matthew Lowe, DO
Co-Authors: David Kasick, MD, Richard Gilchrist, MD, John
Campo, MD
Purpose: To discuss a case of catatonia in a Mennonite
adolescent with ventriculomegaly, review relevant literature,
and explore cultural implications.
Methodology: Case description and literature review.
Results: A 16-year-old Mennonite male was admitted to the
neurosurgery service of an academic medical center with
a four week history of confusion, disorientation, catatonia,
disorganized thinking and behaviors, visual hallucinations,
paranoid delusions, panic attacks, and intermittent suicidal
ideation. There was no prior history of psychiatric disorder
or treatment, and no history of alcohol, drug, or tobacco
use. On examination, he displayed periodic staring, grimacing,
echolalia, echopraxia, perseveration, and impulsivity.
Laboratory evaluation was essentially normal. Brain MRI
showed previously unrecognized right-sided ventriculomegaly.
A right ventriculoperitoneal shunt was placed with resolution
of ventriculomegaly on repeat MRI. Risperidone 0.5mg
BID was initiated and increased to 1mg BID after transfer to
19
inpatient psychiatry, where improvements in disorganized
thinking, speech, and behaviors were noted. Echopraxia
persisted, but resolved completely after a single 2mg dose
of lorazepam. Neurosurgery identified no abnormalities on
two-week follow up and recommended no further workup
or monitoring. The patient has slowly returned to his previous
level of functioning. Follow up call at three weeks revealed
no return of echopraxia after one dose of lorazepam
and continued risperidone. Literature review revealed little
regarding catatonia in association with ventriculomegaly or
hydrocephalus. The family’s Mennonite culture likely influenced
problem recognition and service use.
Conclusion: This first reported case of echopraxia with
ventriculomegaly as a possible cause gives further credence
to searching for organic causes of psychiatric symptoms.
47. Malnutrition due to Sustained Catatonia
in an Ethiopian Male - A Case Presentation,
Literature Review, and Cultural Discussion
Presenting Author: Matthew Lowe, DO
Co-Author: David Kasick, MD
Purpose: To discuss a case of malnutrition due to catatonia
in an Ethiopian male with review of the literature and discussion
of the cultural implications of the case.
Methodology: We present a 26-year-old Ethiopian male
admitted to an academic medical center internal medicine
service due to malnutrition. His BMI was 9. He was sleeping
4 hours. He was receiving haloperidol and quetiapine
for increasing agitation. Psychiatry evaluation noted staring
with catatonic features: mutism, poor focus, negativism, social
withdrawal, gegenhalten, and posturing. He did not talk
or interact with hospital staff. Family reported he knew little
English. He lived in Ethiopia until age of 19 and lived with
his aunt in Sri Lanka for 7 years. He had moved to the U.S. 2
months earlier to join his mother because family felt he may
respond to her. Bloodwork showed malnutrition. Head CT
showed cerebral atrophy. Continued anorexia necessitated
an ICU transfer. One dose of Lorazepam 2mg was given for
continued catatonic behaviors. He was then interactive with
staff and surprisingly spoke English. He was able to feed
himself. Nutritional status improved before discharge. Lorazepam
was scheduled to continue outpatient.
Results: A literature review revealed few reports of malnutrition
caused by catatonia. The family’s Ethiopian culture
and lack of fluency in English influenced treatment in this
case. Due to lack of available psychiatry services in Sir Lanka,
this patient did not receive early intervention.
Conclusion: A followup medical contact revealed no catatonic
symptoms and gradual improvement in nutritional status
with continued lorazepa