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Catatonia and extrapyramidal signs: case report A 25-year-old woman developed catatonia and extrapyramidal signs during anti-psychotic treatment with haloperidol and loxapine. Additionally, amisulpride was also considered to have induced the catatonia. The woman, who was treated with methotrexate for systemic lupus erythematosus (SLE) at the age of 18 years, was provisionally diagnosed with SLE-related psychosis following hospitalisation. She was treated with methylprednisolone, followed by prednisolone and hydroxychloroquine; however, no effects were observed on psychosis. Also, she was treated with cyclophosphamide and plasma exchange, without any effect. Then, she started receiving oral haloperidol 5 mg/day for the psychotic syndrome, but no effect was noted. However, she developed developed neuroleptic-related catatonia (secondary to haloperidol), which was characterised by a catatonic syndrome, including catalepsy-posturing, excitement, staring, rigidity and negativism, along with extrapyramidal signs, such as cogwheel, tremors and rigidity. Also, she developed a complication of aspiration pneumonia. Haloperidol was stopped, and the woman was treated with lorazepam, which resolved the catatonia within 24 hours. Then, lorazepam was stopped, and the catatonia was considered to have been induced by haloperidol. Subsequently, her underlying condition progressed to a severe psychomotor agitation and aggressiveness with invasive auditory hallucinations, and she was moved to psychiatry inpatient unit. She was treated with cyamemazine and olanzapine over 3 weeks; however, she experienced worsening of the psychosis and psychomotor agitation, with the development of mood exaltation, decreased sleep requirement, distractibility and delusions of Capgras. Then, the treatment was switched to valproate to control the manic features. Also, she started receiving amisulpride [route and dosage not stated] for the psychotic syndrome. However, no improvement was observed within 3 weeks. She was treated with a single IM loxapine 100mg and diazepam for the psychomotor agitation and physical aggressiveness. Immediately thereafter, she exhibited catatonic signs, such as withdrawal, immobility, mutism, waxy flexibility, catalepsy, posturing and staring, which were associated with sialorrhoea, tremors and cogwheel rigidity. She was treated with tropatepine for the extrapyramidal signs, without any effect. Based on the Bush-Francis catatonia screening instrument with a score of 20/69, a diagnosis of catatonia secondary to amisulpride and loxapine was confirmed. Subsequently, amisulpride was stopped. She was treated with zolpidem, with the resolution of the psychotic and catatonic syndromes within 30 minutes. The effect lasted for approximately 3 hours. The treatment was switched to lorazepam, and the psychotic symptoms re-developed. Therefore, the woman’s treatment with loxapine was reinitiated at a lower dose. Immediately thereafter, she developed neuroleptic-related catatonia, with catatonic and extrapyramidal signs, with a score of