A Psychiatric Patient With Catatonia and Pulmonary Thromboemboli

To the Editor: Our patient, a 34-year-old woman with a previous diagnosis of bipolar mood disorder from childhood and a previous episode of treated catatonia, was brought to the emergency ward because of refusing to eat and talk for the last week. The patient had first become depressed and restless, stopped her psychiatric medication, and then stopped eating. She had gradually become ill and weak and lay down in her bed, awake, not paying any attention to her surroundings.

At her first visit, she was lying down on the bed, with closed eyelids, refusing to open them. She showed mutism and negativism, but no rigidity or waxy flexibility. She did not have a fever or any other positive finding on her physical examination. She had a normal sinus rhythm and normal heart rate without any abnormal findings on her electrocardiogram. Her routine lab tests were also normal. The initial diagnosis was catatonia, and she was treated with 2 mg of oral lorazepam, every 8 hours.

On the second, third, and fourth days, her mental status did not change, other than eating and drinking a little bit. The internists recommended intravenous infusion of 2 L of normal saline every 12 hours. On the fifth day, the patient became febrile and had a creatinine phosphokinase (CPK) rise of 3,235 and a lactate dehydrogenase (LDH) of 911. Because of poor response to benzodiazepines, electroconvulsive shock (ECT) was administered. On the sixth day, she received a session of ECT. In her lab tests, she had a rise in her liver enzymes; SGPT was 623, and SGOT was 909; CPK was reduced to 1,400. In the afternoon of that day, she started to have respiratory distress and became restless. Her axillary temperature was 38.1°C, and her respiratory rate was 30/min. She had a rise in BUN, creatinine, and BS, and a decline in calcium, hemoglobin, and platelet count. She also had a high white blood cell count (WBC). In her abdominal ultrasonography, she had an enlarged liver, with a normal echo signal, and an enlarged bladder, with 700 ml of urine. The internists ordered subcutaneous enoxaparine and a Foley catheter. After 3 hours, and a relative relief of symptoms, she started to have respiratory distress again, this time with a decline in the level of consciousness, low blood pressure, weak distal pulses, tachycardia, and cold extremities. She was transferred to the CCU, and treated with oxygen, heparin, and dopamine. In her electrocardiogram, she had sinus tachycardia, S1Q3T3 pattern with a prolonging in the Q–T interval, and a strain pattern in V1 to V3. On echocardiography, she had right atrial dilatation, mild pulmonar and tricuspid insufficiency, and a mobile mass in the right atrium. Because of unstable vital signs, brain and thorax computed tomography (CT) scans and CT angiography were not done.

On the morning of the seventh day, the patient showed delirium. She had tachycardia and a variable blood pressure. She still had a high WBC count, hyperglycemia, hypocalcemia, and a rise in BUN and creatinine. All of the psychiatric medications were discontinued, and the heparin was continued. On the afternoon of that day, she had a decline in consciousness and cardiovascular collapse. Cardiopulmonary resuscitation was not successful, and, unfortunately, our patient expired.