Antipsychotics
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Ali S, et al. Encephalitis and catatonia treated with ECT. Cognitive and Behavioral 801103347 Neurology 21: 46-51, No. 1, Mar 2008 - Canada
Exacerbation of catatonia in patients with encephalitis, treated with ECT: 2 case reports Two women with encephalitis experienced worsening of catatonic symptoms while receiving antipsychotic agents. They were successfully treated with electroconvulsive therapy (ECT). The first woman, aged 41 years, received haloperidol [dosage not stated], lorazepam and benzatropine for agitation; she had been hospitalised with a number of psychiatric symptoms. On hospital day 4, she experienced a presumed acute dystonic reaction. Haloperidol and benzatropine were stopped, and improvement was seen with lorazepam. Viral or autoimmune encephalitis was included in the differential diagnosis. An examination revealed diffuse bradykinesia and hyper-reflexia. All psychotropic medications were withheld and she was treated with lorazepam. Olanzapine, which she had been receiving as needed [5mg at night; duration of treatment and therapeutic indication not clearly stated], was withheld. Her altered mental status and agitation continued. Symptomatic management with lorazepam with haloperidol and various atypical antipsychotics [drugs, dosages and durations of treatment not stated] was attempted. She was also sedated with propofol for safety reasons, but her agitation and confusion persisted. Treatment with carbamazepine resulted in low WBC count, and she did not respond to valproic acid. Some benefit was seen with sublingual olanzapine [dosage not stated], gabapentin and IV lorazepam. By hospital week 7, her psychiatric symptoms had deteriorated, and she developed pulmonary emboli and aspiration pneumonia necessitating appropriate treatment. She then developed a fever. At that time she had a number of symptoms of limbic encephalitis. Some improvement was seen with IV lorazepam, and she also received empirical antibacterials. Olanzapine as needed was continued. ECT was started once her fever had resolved and a permanent pacemaker was inserted. After 19 ECT sessions, her cognitive status and frontal lobe functioning had improved and she was discharged following rehabilitation. Her condition was dramatically improved at 6 months’ follow-up. The second woman, aged 22 years, was hospitalised with suspected herpes simplex virus encephalitis. Initially, quetiapine 12.5mg nightly [duration of treatment not stated] was prescribed for agitation, before being replaced with olanzapine 5mg at night for psychosis and oral haloperidol 1mg every 6 hours as needed. Following a psychiatric evaluation IV haloperidol [dosage not stated] was started for her agitation, which was presumed to be secondary to her encephalitis. Her abnormal behaviours continued for 2 days with intermittent nonresponsiveness and episodes of screaming. Olanzapine was discontinued, and initially she improved. However, 4 days later she experienced a catatonic episode thought to be secondary to encephalitis complicated by antipsychotic therapy.
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