Clinical Neurology and Neurosurgery 184 (2019) 105375 Contents lists available at ScienceDirect Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro Why do neurologists miss catatonia in neurology emergency? A case series T and brief literature review ⁎ Sucharita Ananda, Vimal Kumar Paliwala, , Laxmi S Singha, Ravi Uniyalb a Department of Neurology, SGPGIMS, Raebareli road, Lucknow, UP, India b Department of Neurology, King George Medical University, Lucknow, UP, India ARTICLE INFO ABSTRACT Keywords: Catatonia is a well-described clinical syndrome characterized by features that range from mutism, negativism Catatonia and stupor to agitation, mannerisms and stereotype. Causes of catatonia may range from organic brain disorders Extrapyramidal disorder to psychiatric conditions. Despite a characteristic syndrome, catatonia is grossly under diagnosed. The reason for Parkinsonism missed diagnosis of catatonia in neurology setting is not clear. Poor awareness is an unlikely cause because Major depression catatonia is taught among conditions with deregulated consciousness like vegetative state, locked-in state and Schizophrenia akinetic mutism. We determined the proportion of catatonia patients correctly identified by neurology residents in neurology emergency. We also looked at the alternate diagnosis they received to identify catatonia mimics. Twelve patients (age 22–55 years, 7 females) of catatonia were discharged from a single unit of neurology department from 2007 to 2017. In the emergency department, neurology residents diagnosed none of the pa- tients as catatonia. They offered diagnosis of extrapyramidal syndrome in 7, meningitis in 2, and conversion reaction, acute psychosis/encephalopathy and non-convulsive status epilepticus in one each. Their final diag- nosis at discharge was catatonia due to general medical condition in 6 (progressive supranuclear palsy in 2, post- status epilepticus, uremic encephalopathy, glioblastoma multiforme and tuberculous meningitis in one each), catatonia due to major depression in 4, schizophrenia and idiopathic catatonia in one each. Extrapyramidal syndrome appeared as common mimic of catatonia. The literature reviewed also revealed the majority of organic catatonia secondary to causes that are usually associated with extrapyramidal features. Therefore, we suggest that neurologists should consider catatonia in patients presenting with extrapyramidal syndromes. 1. Introduction not specified” [1,6]. The causes of catatonia are a myriad ranging from pure psychiatric illnesses to neurological diseases like encephalitis and Catatonia is a mysterious disorder that is characterized by at least neurodegenerative conditions. Despite a characteristic clinical entity, three of the following - negativism (not following or resisting com- catatonia is under recognized in neurology clinics. This can be attrib- mands), bizarre posturing, catalepsy (maintaining the induced anti- uted to frequently changing diagnostic criteria of catatonia, low sensi- gravity postures), mutism, waxy flexibility (resisting passive move- tivity of diagnostic criteria, other neurological conditions sharing ment), grimacing, echolalia, echopraxia, stupor, mannerisms, agitation clinical features with catatonia and poor awareness of this condition and stereotype. Catatonia was first described and proposed as a sepa- [7]. rate disorder by Karl Ludwig Kahlbaum in 1874 [1]. Emil Kraepelin and We performed this retrospective study to understand the reason for later Eugen Bleuler associated catatonia with schizophrenia in the early delayed/missed diagnosis of catatonia in neurology settings. We aimed 1900s [2,3]. Catatonia was a pure psychiatric condition till late 1900s. to determine the proportion of patients that were correctly diagnosed as However later, catatonia was also seen in patients suffering from af- catatonia by neurology residents. We also aimed to compare the initial fective disorders and general medical conditions [3–5]. Therefore, re- diagnosis offered to these patients in the neurology emergency by cent Diagnostic and Statistical Manual of Mental Disorders 5th edition neurology duty residents to the final diagnosis they received at the time (DSM V) criteria classify catatonia as “catatonia secondary to general of discharge from hospital in order to identify the important clinical medical condition”, “catatonia as a specifier for schizophrenia”, “cata- mimics of catatonia. We also reviewed the literature on patients with tonia as a specifier for affective disorders” and “catatonia with cause catatonia secondary to neurological and medical conditions. ⁎ Corresponding author. E-mail address: [email protected] (V. Kumar Paliwal). https://doi.org/10.1016/j.clineuro.2019.105375 Received 2 August 2018; Received in revised form 9 May 2019; Accepted 21 May 2019 Available online 22 May 2019 0303-8467/ © 2019 Elsevier B.V. All rights reserved. S. Anand, et al. Clinical Neurology and Neurosurgery 184 (2019) 105375 2. Methods We collected the details of the catatonia patients that were dis- charged from a single unit of the department of Neurology from 2007 to 2017. The case files of the patients were evaluated for their presenting clinical features, examination findings, initial diagnosis made by the neurology residents, investigations, catatonia days, hospitalization days and the final diagnosis at the time of discharge. Based on the presenting clinical features, all patients were subjected to the DSM V criteria for catatonia. Patients fulfilling the DSM V criteria for diagnosis ofcata- tonia were included in the study. The patients were also subjected to the DSM IV criteria and Bush Francis Catatonia Rating Scale (BFCRS) [6,8,9]. Catatonia was classified as: Etiology Major depressive disorder recurrent Catatonia due to GMC Major depressive disorder recurrent Catatonia due to schizophrenia Catatonia due to GMC (PSP) Catatonia due to GMC (PSP) Major depressive disorder recurrent Catatonia related to GMC (bi-fronatalepilepsy, gliosis, SE) Catatonia due to GMC (Glioblastoma multiforme frontal lobe) Catatonia due to GMC (TBMparadoxical with reaction) tuberculoma? Major depressive disorder recurrent Operated case of Schwannoma Catatoniaotherwise not specified 1 Malignant catatonia - characterized by presence of hyperthermia, fever and features of neuroleptic malignant syndrome 2 Periodic type which can be either hyperkinetic or hypokinetic [10]. 3. Results Precipitating cause Prokinetics (domperidone) Acute renal failure,? prokinetics “Bhang” (cannabis) addiction Twelve patients fulfilled the DSM V criteria for the diagnosis of – Septicemia – Status epilepticus Antipsychotic drugs None catatonia. All twelve patients also fulfilled DSM IV criteria and BFCRS. Seven patients were females. Age of the patients ranged from 22 to 55 years. Duration of catatonic symptoms was less than 5 days in 4 patients and 5 to 15 days in 7 patients and 1 month in 1 patient. The clinical details of the patients are given in Table 1. The frequencies of different clinical features of catatonia inde- creasing order were waxy flexibility, mutism, negativism, catalepsy, stereotypies, agitation and echolalia. None of our patient had stupor, mannerisms, posturing, grimacing and echo-praxia. Initial diagnosis that was offered to patients after their first clinical examination in the emergency department was extrapyramidal syn- drome (seven patients). Two patients were diagnosed with meningitis, and one each was diagnosed as acute psychosis/encephalopathy, con- version reaction and non-convulsive status epilepticus. The neurology residents diagnosed none of the patient with catatonia or with any brain metastasis of tumor/Metastasis primary psychiatric condition. The final diagnosis at the time of dis- charge were catatonia due to general medical condition (GMC) in six patients, catatonia due to major depressive disorder recurrent in four Duration Initial Diagnosis 1 month Drug induced extrapyramidal5 disorder days Acute7 psychosis/encephalopathy days Drug7 induced days extrapyramidal disorder Conversion reaction patients, catatonia due to schizophrenia in one patient and catatonia 15 days PSP, Operated carcinoma breast with suspicion7 of days3 days Extrapyramidal syndrome, hypertension Non-convulsive15 SE days Chronic meningitis?Chronic2 subdural days hematoma TBM2 relapse,? days paradoxical reaction,? VP None 5 shunt days failure Drug induced None extrapyramidal syndrome Drug induced extrapyramidal syndrome? Recurrence not otherwise specified in one patient. Seven patients who were offered a diagnosis of extrapyramidal syndrome in the neurology emergency by duty residents actually suf- fered from catatonia secondary to major depressive disorder recurrent (four patients), progressive supra-nuclear palsy (PSP) (two patients) and catatonia not otherwise specified (one patient). Six patients with the final diagnosis of “catatonia due to general medical condition” had PSP in two patients, acute renal failure, epilepsy with bi-frontal gliosis, glioblastoma multiforme (GBM) and tuberculous meningitis (TBM) in one patient each. None of our patient had malignant catatonia. Two patients had hyperkinetic episodic catatonia whereas ten patients had hypokinetic episodic catatonia. Prokinetic drugs precipitated catatonia in two patients. Cannabis intake, status epilepticus and septicemia were the probable precipitating causes of catatonia in one patient each. (Table 1) Ten patients received lorazepam and two patients received