Delirium, catatonía y síndrome de abstinencia manifestados como agitación psicomotora en COVID-19: una propuesta de manejo farmacológico en el hospital general / Delirium, catatonia and substance withdrawal syndrome manifested as psychomotor agitation in COVID-19: a pharmacological management approach for the general hospital setting

BACKGROUND: Neuropsychiatric symptoms can be part of the clinical spectrum of COVID-19 infections. AIM: To devise an evidence based clinical algorithm as a guide for clinicians, to identify and treat underlying clinical syndromes of psychomotor agitation, such as delirium, catatonia or substance withdrawal in patients who are hospitalized and infected with SARS-CoV-2. MATERIAL AND METHODS: A review of the literature about the pharmacological management of neuropsychiatric manifestations of COVID-19 at the general hospital, to develop a clinical protocol based on a consensus from an interdisciplinary expert panel at a Clinical Hospital. Results: A consensual clinical algorithm for the management of delirium, catatonia, and substance withdrawal, manifested as psychomotor agitation in patients hospitalized with COVID-19, was developed as a clinical proposal for physicians at different levels of complexity in health services. CONCLUSIONS: Cooperation among different clinical units in the general hospital facilitated the implementation of a clinical algorithm for clinicians for the management of psychomotor agitation in COVID-19 patients.

Viraje de fase maníaca a catatonía por noxa somática aguda / Manic phase shift to catatonia by acute somatic noxa

El síndrome catatónico como entidad neuropsiquiátrica ha sufrido cambios conceptuales a través de la historia, incluyendo tanto la clínica de su presentación como sus posibles causas. Éste último elemento cobra especial importancia, dado que la catatonía puede presentarse tanto por diversos cuadros médicos así como por patología psiquiátrica primaria. Se presenta el caso clínico de una paciente con antecedente de trastorno afectivo bipolar ingresada por un episodio maníaco con síntomas psicóticos asociados a un evento vital estresante. La paciente, durante una infección respiratoria baja, cambia su presentación clínica, objetivándose elementos propios de un estupor depresivo y síndrome catatónico. Una vez tratado el cuadro infeccioso y descartadas las causas neurológicas de la catatonía, se realizó tratamiento con benzodiacepinas, iniciándose luego fármacos para depresión bipolar, obteniéndose excelente respuesta clínica. Se pretende en este reporte dar a conocer la importancia de detectar elementos catatoniformes en pacientes psiquiátricos ingresados en unidades de corta estadía, así como buscar siempre posibles causas médicas relacionadas.

The catatonic syndrome as a neuropsychiatric entity has undergone conceptual changes throughout history, including both the clinical presentation and its possible causes. This last element is particularly important, given that catatonia can occur both in different medical situations as well as in primary psychiatric pathology. We present the clinical case of a patient with a history of bipolar affective disorder, hospitalized because of a manic episode with psychotic symptoms associated with a stressful life event. The patient, during a low respiratory infection, changes its clinical presentation, with elements of a depressive stupor and catatonic syndrome. Once the infectious symptoms were treated and the neurological causes of catatonia were ruled out, treatment with benzodiazepines was carried out, and then drugs for bipolar depression were started, obtaining an excellent clinical response. The aim of this report is to make known the importance of detecting catatoniform elements in psychiatric patients admitted to short-stay units, as well as to look for possible related medical causes.

Catatonia ictal en el Servicio de Urgencia: una rara forma de presentación del estado epiléptico no convulsivo / Ictal catatonia presentation as a non-convulsive status epilepticus: a case report

The differential diagnosis of non-convulsive status epilepticus (NCSE) is often complex due to a wide clinical variability of its presentation, including psychiatric manifestations. We report a 68 years old male with a history of depression treated with venlafaxine, mirtazapine, quetiapine and risperidone, presenting in the emergency room with confusion and generalized rigidity. A brain CT scan did not show lesions. A neuroleptic syndrome was initially suspected. At the third day the obtundation worsened and an electroencephalogram (EEG) was performed, which showed epileptiform abnormalities. Treatment with valproic acid resulted in disappearance of such abnormalities. After three weeks of mechanical ventilation, the patient was extubated and remained lucid and partially orientated in time and space.

Síntomas psicóticos, paranoides y catatónicos como debut de enfermedad de Cushing en una paciente con síndrome de Turner: reporte de caso y revisión de la literatura / Psicotic, paranoid and catatonic symptoms as Cushing disease onset in a Turner syndrome patient: case report and literature revision

It is known that hipercortisolism and overactivity of the Hypotalamus pituitary adrenal axis are associated to psiquiatric diseases presentation. In patients with Cushing syndrome, mood disorders are common, also psicosis cases also are present during the disease. But, the presence and mostly the onset with a episode of catatonic psicosis is unusual. The cortisol excess produce structural damage in the Central Nervous System, reversible and irreversible, specially in the hypocampus. We show the case of a young woman with previous diagnostic of Turner syndrome, karyotype 45 X0, who presented a psychiatric episode caracterized for depresive psicotic symptoms and posteriorly a catatonic state as an unusual form of Cushing disease onset. This patient presented health improvement after pituitary resection. There is not evidencia that Turner syndrome influes over this unusual form of presentation.

Se conoce que el hipercortisolismo y la sobreactividad del eje hipotálamo pituitario adrenal están asociados a la presentación de enfermedades psiquiátricas. En pacientes con síndrome de Cushing son frecuentes los trastornos del ánimo aunque también se presentan casos de psicosis durante el curso de la enfermedad. Sin embargo es inusual la presencia y más aún el debut con un cuadro de psicosis catatónica. El exceso de cortisol produce daño estructural en el sistema nervioso central tanto reversible como irreversible, especialmente en el hipocampo. Presentamos el caso de una paciente mujer joven con diagnóstico previo de síndrome de Turner, cariotipo 45 X0, quien presentó un cuadro psiquiátrico caracterizado por síntomas depresivos psicóticos y posteriormente catatonia como forma inusual de debut de enfermedad de Cushing y presentó mejoría posterior a la resección de la pituitaria. No se tiene evidencia que el síndrome de Turner influya sobre esta rara forma de presentación.

Out Come of Bipolar I (Mania) Disorders, In Relation to Catatonic Symptoms.

The purpose of this study was to understand and probably explain the variability in symptomatology particularly with presence of catatonic symptoms and treatment response to lorazepam in mania. Methods: 52 patients of bipolar disorder were selected from admitted patients in psychiatry ward from P.B.H. Hospital, Bikaner. Structural Clinical Interview for DSM IV patient version (SCID-P) item Young Mania Rating Scale, 23 item Bush Francis Catatonia Screening Instrument and Rating Scale. 43 item Presumptive stressful Life Event Scale, were administered. Statistical tests were performed using SPSS version 9.0 were Pearson’s correlation Chi square analysis, test, ANOVA. Results: Only 3 patients out of 14 patients of first Manic episode showed good outcome. Patients with history of multiple episodes had shown better outcome (X2 = 11.59, df = 1, p < 0.00) The authors noted that the presence of catatonic symptoms (X2 = 17.76, df – 2, p < 0.001), high catatonic scores (F = 37.18, df = 2, 49, p < 0.000), and high reduction in catatonic score after Lorazepam challenge were associated with better outcome. There was strong negative correlation between index, catatonic and Mania Scores in grade I and grade II outcome category, (p < 0.000). Conclusions: This is a preliminary study to suggest that the presence of catatonic symptoms had better outcome in bipolar patients.

Catatonia and Wilson's disease

A 17-year-old girl presented with lower limb oedema, chronic diarrhea, psychomotor retardation and insomnia. Laboratory investigations revealed a slight elevation of total bilirubin, hypoalbuminaemia, target cells in the blood film, thrombocytopenia, prolonged prothrombin and partial thromboplastin times noncorrected by vitamin K injections, increased urinary copper, decreased serum copper, and decreased blood ceruloplasmin. Active micronodular cirrhosis was found on liver biopsy. Slit lamp examination of the eyes revealed Kayser-Fleischer rings, and neuropsychiatric examination revealed a catatonic state with no obvious cardinal neurological manifestations of Wilson's disease. To date there are no reported cases of catatonia associated with Wilson's disease and we believe that our patient was the first patient to be described with catatonia associated with Wilson's disease. Wilson's disease should be considered in the differential diagnosis of catatonia

Síndrome catatônica por doença auto-imune: recuperaçäo espontânea / Catatonic syndrome caused by autoimmune disease: spontaneous remission

O conhecimento das manifestaçöes psiquiátricas do Lúpus Eritematoso Sistêmico (LES) e de outras doenças auto-imunes é importante, tanto para o clínico como para o psiquiatra, uma vez que elas podem preceder de muitos anos as manifestaçöes sistémicas. Neste estudo é apresentada uma paciente com síndrome catatónica näo associada a distúrbios metabólicos e cuja evoluçäo näo foi de uma doença esquizofrênica. A paciente apresentava imunocomplexos liquóricos durante a crise e as provas imunológicas mostravam a presença de imunocomplexos circulantes, FAN positivo (1/800) com padräo nucleolar a imunofluorescência. O quadro clínico regrediu concomitantemente com a negativaçäo dos imunocomplexos liquóricos e com a acentuaçäo dos imunocomplexos circulantes, sem o uso de imunossupressores. A síndrome cataônica é uma manifestaçäo rara em pacientes com doença auto-imune e poucos säo os casos relatados sem manifestaçöes sistêmicas concomitantes. Este estudo clínico mostra que devemos estar atentos para as manifestaçöes psiquiátricas das doenças auto-imunes e que alguns marcadores como imunocomplexos liquóricos säo de grande valia para o seu diagnóstico e poderäo revelar que este tipo de manifestaçäo é mais freqüente do que revela a literatura

Catatonia como uma síndrome inespecífica / Catatonia as an inespecific syndrome

A literatura especializada internacional tem acumulado evidências de que os sintomas catatônicos, por muito tempo considerados patognomônicos de um subtipo de esquizofrenia, podiam ter variadas etiologias. O presente trabalho trata de revisar, retrospectivamente, os diagnósticos finais de diversos casos internados na UIP-HCPA, nos últimos três anos, com diagnóstico inicial de síndrome catatônica ou diagnóstico final de esquizofrenia catatônica. Os achados confirmam a impressäo atual de que a catatonia é uma síndrome inespecífica e näo restrita à esquizofrenia

Síndrome catatônica de etiologia orgânica: relato de dois casos / Organic etiology of catatonic syndrome: report of 2 cases

Faz-se uma breve revisäo da literatura concernente à catatônia experimental, particularmente à catatônia colibacilar de Baruk. Dois pacientes acometidos por abscessos conseqüentes a acidente ofídico por serpentes do gênero Bothrops, ocorrido em janeiro de 1986, desenvolveram síndrome catatônica e foram submetidos à avaliaçäo clínico-laboratorial. A bacteriocultura revelou a presença de Escherichia coli na secreçäo dos abscessos, microorganismo muito comum na flora saprófita da cavidade oral de serpentes deste gênero. Traça-se, entäo, hipótese etiopatogênica para a síndrome catatônica a partir da infecçäo dérmica colibacilar, em analogia com casos descritos na literatura, onde notamos afecçöes catatoniformes conseqüentes a infecçöes urinárias, entéricas, biliares e puerperais, causadas pela Escherichia coli