Cannabis-Induced Catatonia in a 15-Year-Old Male: A Case Report

Introduction: Catatonia is a syndrome of primarily psychomotor disturbances most common in psychiatric mood disorders but that also rarely has been described in association with cannabis use. Case Presentation: A 15-year-old White male presented with left leg weakness, altered mental status, and chest pain, which then progressed to global weakness, minimal speech, and a fixed gaze. After ruling out organic causes of his symptoms, cannabis-induced catatonia was suspected, and the patient responded immediately and completely to lorazepam administration. Discussion(s): Cannabis-induced catatonia has been described in several case reports worldwide, with a wide range and duration of symptoms reported. There is little known about the risk factors, treatment, and prognosis of cannabis-induced catatonia. Conclusion(s): This report emphasizes the importance of clinicians maintaining a high index of suspicion to accurately diagnose and treat cannabis-induced neuropsychiatric conditions, which is especially important as the use of high-potency cannabis products in young people increases.Copyright © 2023, State Medical Society of Wisconsin. All rights reserved.

Ketamine as an alternative to ECT in catatonia in elderly women with bipolar disorder: A case report.

The following paper described two cases of patients with catatonic depression in bipolar disorder (BD) referred to our electroconvulsive therapy (ECT) service. Both were deemed not medically fit for ECT, and were, instead, treated with intravenous (IV) ketamine. Both responded with a resolution of symptoms, returning to baseline level of functioning. During the COVID-19 pandemic, given the risks associated with providing ECT (an aerosol generating procedure) and, in the context of limited resources, ketamine therapy for catatonia is a potentially beneficial alternative or supportive treatment to ECT that merits additional research.

Successful ECT in an adolescent with catatonia and psychosis due to COVID-19.

This case report highlights the use of ECT in an adolescent patient with a COVID-19 infection, which is an area of limited data. The patient received a full course of bitemporal ECT, with a total of 15 treatments administered over four months. The patient responded robustly, with a complete return to her pre-infection baseline mental status, and response has remained durable for one-year post continuation phase ECT taper. Maintenance ECT considerations for catatonia should be determined on a case-by-case basis but was not needed for our patient, given the durability of the response to ECT.

A rare case of Guillain barre syndrome with overlapping cerebral sinus venous thrombosis masquerading as acute psychosis following COVID-19 vaccination

Guillain barre syndrome (GBS) is a rare autoimmune condition that has a prevalence of 1-2 per 100,000 people each year. Cerebral sinus venous thrombosis (CSVT) occurs at a rate of three to four cases per one million individuals annually. Both have variable clinical presentation with significant morbidity. The therapeutic management of CSVT and GBS presents unique challenges due to peculiar relationship and overlap in presentation. Reports suggest that psychosis may result from autoimmune encephalitis after receiving the COVID-19 vaccination. Hereby the reported case is of a female who is 18 years of age presenting with acute psychotic and catatonic symptoms following covid 19 vaccination with weakening of limbs which suspected an underlying organic pathology. Magnetic resonance imaging was normal but magnetic resonance venogram showed transverse and sigmoid sinus thrombosis and later GBS with CSVT after Covid-19 vaccination was diagnosed. The case was chosen to report a rare condition with an atypical

Moving to accelerated protocols of tDCS in schizophrenic catatonia: A case report

This is a case report of a 74-year-old woman with catatonic schizophrenia who was treated with transcranial Direct Current Stimulation (tDCS) in place of electroconvulsive therapy (ECT) during the Covid-19 pandemic that impacted access to ECT facilities. In 2021, the exceptional number of patients infected with SARS-Cov-2 led the French public hospital system to adjust its organization, temporarily redirecting anesthetists from ECT departments to ICUs. Our patient, who was hospitalized via the emergency department, presented schizophrenia with catatonic features. Due to the pandemic, ECT, which is considered the gold standard treatment for this condition, was not available. Therefore, tDCS, a neuromodulation technique that doesn't require general anesthesia, was recommended for this patient, and was delivered at the relatively (compared to standard protocols) accelerated rate of five sessions a day, five days a week. This protocol was chosen as accelerated rTMS had been shown to be effective against depression in recent trials (Cole et al. 2021), and one study had also reported this exact protocol as effective and harmless for a patient with schizophrenia (Mondino et al. 2021). The Bush-Francis Catatonia Rating Scale (BFCRS) was used to evaluate the severity of the catatonia. After 49 sessions, the clinical response was meaningful, with a BFCRS score of 16, compared to 36 at baseline. We then moved to five sessions a day, three days a week, and then two days a week. After 80 sessions, we noted the complete disappearance of catatonia (BFCRS = 6). This case provides evidence for the feasibility and tolerability of accelerated tDCS for patients with catatonia. Accelerated tDCS represents a potential alternative to ECT in the treatment of catatonia, and needs further randomized clinical studies to confirm its efficacy. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: tdcs, catatonia, covid-19, ECTCopyright © 2023

A case of catatonia in the aftermath of the COVID-19 pandemic: Does autism spectrum matter?

Background: There is growing concern about the psychopathological consequences of the COVID-19 pandemic. The prolonged stress due to the spreading fear of the contagion and to the enforced containment measures are deemed to trigger recurrences of preexisting mental disorders as well as the onset of new ones. From such perspective, clinical cases may be of primary ground to identify individual features and pandemic-related factors predisposing to the development of serious psychiatric symptoms. Case presentation: Mr. R. is a 64-year-old, married, unemployed man, whose premorbid personality was characterized by relevant autistic traits. The patient developed catatonia in the context of the COVID-19 pandemic. We aimed at discussing the role of both preexisting and precipitating factors. Conclusions: Autism spectrum could represent a predisposing factor for severe psychopathological outcome and catatonia. Furthermore, the present clinical case highlights the role of COVID-19 pandemic in influencing physical and mental health. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

A case of schizophrenia with relapsed catatonia successfully treated with blonanserin transdermal patch.

BACKGROUND: Catatonia is a syndrome that may present with stupor, immobility, and postural retention, and appears in various primary disorders including schizophrenia, depressive disorders, and neurodevelopmental disorders. CASE PRESENTATION: In this report, we describe a 34-year-old female patient with schizophrenia, who had previously been treated with antipsychotic agents to improve psychotic symptoms with delusional symptoms and catatonia. However, she relapsed with catatonic symptoms around 1 year after she voluntarily discontinued the prescribed antipsychotic medications by herself. Her catatonia was successfully improved using the transdermal blonanserin patch, a drug formulation globally first approved in Japan in 2019. DISCUSSION: Although benzodiazepines or electroconvulsive therapy have been recommended as the first-line treatment of catatonic manifestation observed in psychiatric patients, this patient responded well to antipsychotic blonanserin. From the differential drug responses, catatonia may be the complex of heterogeneous conditions with different pathophysiologies.

Parainfectious autoimmune encephalitis related to SARS-CoV-2 infection, presenting with catatonia.

OBJECTIVE: SARS-CoV-2 infection commonly affects both the central and peripheral nervous systems, resulting in a variety of neurological and psychiatric symptoms. Whereas the effects of SARS-CoV-2 on neuronal structures in the short and long-term are still controversial, neurological involvement secondary to SARS-CoV- 2 is heterogeneous in terms of clinical presentation, treatment response, and prognosis. METHOD: A case of autoimmune encephalitis developing after SARS-CoV-2 is described in this article. RESULTS: The patient was admitted to the clinic with classical signs of catatonia and encephalopathy. The emergence of neuropsychiatric problems after the relief of SARS-CoV-2 symptoms suggests that symptoms were primarily related to immune processes. This patient demonstrated a good clinical response to symptomatic catatonia treatment and immune-modulatory agents and recovered both physically and cognitively without sequelae. CONCLUSION: SARS-CoV-2 infection may involve encephalitic involvement and psychological symptoms (including catatonia) after the infection by triggering autoimmune pathways.

Delayed onset catatonia after COVID-19.

COVID-19 has many complications that are associated with this infection. Neuropsychiatric symptoms are common and can present with symptoms documented both during acute COVID-19 infection and developing after the resolution of respiratory symptoms. Patients have presented with a variety of symptoms such as anosmia, seizures, cognitive and attention deficits, new or progression of existing anxiety, depression, psychosis, and rarely catatonia. Although rare, catatonia and each of its subtypes have now been reported as complications of COVID-19 and therefore, should be considered known to occur in both during the acute and postinfectious states. Diagnosis of catatonia in the context of COVID-19 should be considered when work-up for more common medical causes of encephalopathy are negative. There have been cases documented in the literature of patients presenting to the hospital with catatonia during COVID-19 infection. However, we present a case of akinetic catatonia in setting of COVID-19 infection and premorbid serious mental illness that was diagnosed and treated on an outpatient basis with close collaboration between primary care and psychiatry.

Co-Occurring Catatonia and COVID-19 Diagnoses Among Hospitalized Individuals in 2020: A National Inpatient Sample Analysis.

BACKGROUND: COVID-19 is associated with a range of neuropsychiatric manifestations. While case reports and case series have reported catatonia in the setting of COVID-19 infection, its rate has been poorly characterized. OBJECTIVE: This study reports the co-occurrence of catatonia and COVID-19 diagnoses among acute care hospital discharges in the United States in 2020. METHODS: The National Inpatient Sample, an all-payors database of acute care hospital discharges, was queried for patients of any age discharged with a diagnosis of catatonia and COVID-19 in 2020. RESULTS: Among 32,355,827 hospitalizations in the 2020 National Inpatient Sample, an estimated 15,965 (95% confidence interval: 14,992-16,938) involved a diagnosis of catatonia without COVID-19 infection, 1,678,385 (95% confidence interval: 1,644,738-1,712,022) involved a diagnosis of COVID-19 without a co-occurring catatonia diagnosis, and 610 (95% confidence interval: 578-642) involved both catatonia and COVID-19 infection. In an adjusted model, a diagnosis of COVID-19, but not a diagnosis of catatonia or the combination of catatonia and COVID-19, was associated with increased mortality. Patients with catatonia and COVID-19 were frequently diagnosed with encephalopathy and delirium codes. CONCLUSIONS: Catatonia and COVID-19 were rarely co-diagnosed in 2020, and catatonia diagnosis was not associated with increased mortality in patients with COVID-19. Further research is needed to better characterize the phenomenology of catatonia in the setting of COVID-19 infection and its optimal treatment.

Postpartum Collapse Subsequent to Catatonia in a Female with COVID-19 Infection: a Rare Entity Visited.

Postpartum collapse is a life-threatening condition caused by obstetrical and non-obstetrical events. In this case report, we discuss a case of postpartum collapse in COVID-19-positive woman who required intensive care and mechanical ventilation for two days. After confusing collision of many provisional diagnoses soldiering for three days, she was ultimately diagnosed with malignant catatonia. Targeted therapy with lorazepam challenge resulted in drastic improvement, and she was discharged with her baby in healthy condition.

A Biopsychosocial Formulation of Psychosis after Kidney Transplantation: When Cultural Identity and Biology Collide

Background: When working with colleagues of predominantly biological perspectives, it is an important role of the consultation psychiatrist to recognize psychosocial factors that may be impacting a patient's pathology. This case exemplifies the importance of such education between psychiatric and transplant providers. Case: This is a 38-year-old divorced Russian man, with history of cannabis use and childhood trauma;and history of ESRD secondary to IgA nephropathy s/p DDKT on tacrolimus/mycophenolate/prednisone. Eighteen months after transplantation, in the setting of daily cannabis use, he developed psychosis with persecutory delusions, referential experiences, and experiences of thought alienation. The content of his delusions was tied closely to his experience of emigration from Russia, having spent his childhood in Volgograd/Stalingrad after the dissolution of the USSR. He was found to have a tacrolimus level of 20, above goal-range of 8-10. He was medically hospitalized and followed by psychiatry. The medical, transplant, and psychiatry teams collaborated to downtitrate his tacrolimus and initiate treatment with antipsychotic medication. His psychosis initially improved but recurred six months after discharge. At that time, there were several changes to his presentation of diagnostically significance. His tacrolimus level was found to be within goal. He had also recently recovered from COVID-19, self-discontinued olanzapine, and ceased cannabis use. The patient's new persecutory delusions developed concurrently with the conflict between Russia and Ukraine, raising suspicion that activation of trauma was playing a larger role. Discussion(s): Biologically, the effect of cannabis on immunosuppression through CYP3A4 inhibition is relevant, as is the independent relationship between cannabis, tacrolimus and psychosis1,2 At the time of writing, any effect of the change to belatacept is yet unknown. Psychologically, trauma history likely contributed to suspiciousness toward others and persecutory delusions. There is also evidence to suggest a relationship between trauma, cannabis and psychosis.3 Culturally, his sensation of being targeted was likely related to his Russian identity, immigrant status, and the current international conflict. Conclusion/Implications: This case demonstrates multiple contributing factors to psychosis in a patient post-transplant, which include psychological, trauma-related, and cultural factors in addition to those explained by pathophysiology of transplant, substance use, and immunosuppression. Transplant psychiatry has an essential role in educating our colleagues and patients about the multitude of contributors to psychiatric health post-transplant. References: 1. Nogueira JM, Freire MJ, Nova VV, Jesus G. When Paranoia Comes with the Treatment: Psychosis Associated with Tacrolimus Use. Case Rep Nephrol Dial. 2021;11(2):241-246. 2. Sikavi D, McMahon J, Fromson JA. Catatonia Due to Tacrolimus Toxicity 16 Years After Renal Transplantation: Case Report and Literature Review. J Psychiatr Pract. 2019;25(6):481-484. 3. Tomas-Roig J, Piscitelli F, Gil V, et al. Effects of repeated long-term psychosocial stress and acute cannabinoid exposure on mouse corticostriatal circuitries: Implications for neuropsychiatric disorders. CNS Neurosci Ther. 2018;24(6):528-538. Copyright © 2022

Validating the Busch Francis Scale for use in Telepsychiatry

Background: The COVID-19 pandemic has dramatically accelerated the utilization and acceptance of telepsychiatry, with many departments transitioning to virtual models over the past 2 years out of necessity. While there has been some research on physician and patient satisfaction with the transition, there has been significantly less research on the quality of care provided (Mishkin). By its nature, telemedicine precludes physical examination. While many psychiatric conditions are amenable to diagnosis via patient interview alone, some such as catatonia require a physical exam for diagnosis. The Busch Francis Catatonia Rating Scale (BFCRS) is a well validated in-person exam for catatonia to both screen for and rate the severity of a catatonia diagnosis (Sienaert), but to our knowledge it has not been validated via telemedicine. Our literature review revealed a paucity of research on the contribution of each individual item to the overall sensitivity of the rating scale, thus it is impossible to predict the value of a fully virtual or hybrid exam. We plan to evaluate the inter-relater reliability between an in-person BFCRS performed by a psychiatrist and one supervised by a psychiatrist through telemedicine technology. Current practice at our institution is for the psychiatry resident performing tele-consults to Methods: We will draw participants from the pool of patients for whom psychiatric consults are ordered at two separate medical campuses. Our team will consist of C-L psychiatry fellows performing BFCRS exams patients at these campuses;we will strive to see all patients for whom a psychiatric consultation is ordered. In addition to a standard psychiatric consult (which may or may not include a BFCRS), patients will receive an in-person BFCRS screening exam performed and scored by the research team member at their site and one additional hybrid BFCRS exam scored by the research team member at the alternate site with physical exam components only performed by the onsite research team member. Data collected for each participant will include demographic information, medical and psychiatric diagnoses and BFCRS scores. We will compare the sensitivity and specificity fully virtual (which will by necessity exclude some components such as rigidity) and hybrid BFCRS exam to the full in-person scale, which we will treat as a gold standard. Discussion/Conclusion: This project is currently in early stages. We hope to gather data to inform the future practice of C-L psychiatrists performing consults through telemedicine. Mishkin AD, Cheung S, Capote J, Fan W, Muskin PR. Survey of clinician experiences of telepsychiatry and tele-consultation-liaison psychiatry. J Acad Consult Liaison Psychiatry. Published online November 15, 2021:S2667-2960(21)00184-1. Reference: Sienaert P, Rooseleer J, De Fruyt J. Measuring catatonia: a systematic review of rating scales. J Affect Disord. 2011;135(1-3):1-9 Copyright © 2022

Electroconvulsive Therapy on Patients with Takotsubo Cardiomyopathy: Case Reports and Literature Review

Background/Significance: Electroconvulsive therapy (ECT) is a safe procedure with infrequent cardiovascular complications. Takotsubo cardiomyopathy (TC) associated with ECT has been rarely reported. Cases: JP is a 67-year-old woman with Schizoaffective Disorder, admitted for psychosis and depressive symptoms. ECT was planned given lack of response to multiple antipsychotics, including clozapine, prior to admission. After the first ECT, patient had elevated troponin, EKG with precordial biphasic T-waves and T-wave inversions, prolonged QTc, negative coronary CT angiogram, and apical wall motion abnormality in TTE with preserved LVEF. Cardiac abnormalities were hypothesized to be due to clozapine-related myocarditis, TC, or sarcoidosis, and clozapine was replaced with haloperidol. ECT was resumed and notable for episodes of bradycardia requiring glycopyrrolate, and hypertension requiring labetalol, yet after 12 sessions, most of her psychosis and depressive symptoms remitted. MT is a 50-year-old woman with MDD with psychotic features, admitted after suicide attempt by hanging. While in NICU, patient was found to have TC with anterior T-wave inversion on EKG and apical hypokinesis in TTE. New EKG 12 days later for ECT clearance showed anteroseptal ST changes suggestive of ischemia, but coronary CTA was normal, and repeat TTE showed no segmental wall motion abnormalities. ECT was started without further cardiac issue but was discontinued after 5 sessions due to marked improvement in depressive symptoms while having intermittent episodes of post-ECT fever and COVID infection with multifocal pneumonia. NE is a 68-year-old woman with MDD with psychotic features, catatonia, and suspected TC after ECT in 2007, admitted for severe catatonia. During ECT session 3, patient had 4 seconds of asystole on telemetry, immediately following succinylcholine with rapid return of palpable pulse, stable heart rate and blood pressure. Post-procedure EKG and recent TTE were normal, and ECT was continued with rocuronium and sugammadex instead of succinylcholine given its associated risk of asystole. Patient did not have any further episodes of asystole or arrythmia but required multiple medications for high blood pressure during ECT sessions. Discussion(s): Regardless of whether TC was diagnosed during the course or prior to initiation of ECT, the decision to perform ECT was based on patient's symptoms and overall cardiac function. 20 cases of TC associated with ECT have been reported with successful resumption of ECT in 8 cases and varying use of beta-blocker to prevent secondary TC. The reported time between TC and ECT ranges from weeks to months, with our cases being approximately 2 weeks (Medved 2018). Conclusion/Implications: ECT can be safely performed on patients with recent, including intercurrent, or remote TC with pharmacological management to mitigate cardiovascular risks. Reference: Medved S, et al: Takotsubo cardiomyopathy after the first electroconvulsive therapy regardless of adjuvant beta-blocker use: a case report and literature review. Croat Med J. 2018;59:307-12. Copyright © 2022

Postpartum Depression, Catatonia and Covid-19 Infection: One Case, Different Clinical Presentations

Introduction: Post-partum depression may occur in the first year after childbirth in approximately 25% of women, at times presenting with psychotic symptoms and catatonic states. Catatonia is a psychomotor syndrome that occurs in association with various neuropsychiatric disorders and can be described according to the characteristics of its manifestation in types such as retarded or agitated. Objective(s): We report the case of a patient with postpartum depression and catatonic syndrome who, after a session of electroconvulsive therapy, was infected with Sars-COV-2, suspended treatment, and had her condition aggravated with distinct clinical manifestations. Method(s): Clinical case report and non-systematic review of articles consulted in the PubMed platform. Result(s): A 24-year-old patient develops depressive symptoms and obsessive behaviour 6 months after delivery and deteriorates with mutism, stupor and motor immobility. She was hospitalised and medicated with lorazepam, with no improvement. One session of electroconvulsive therapy was carried out with improvement of the symptoms. Due to an inpatient Covid-19 outbreak, in which the patient was infected, treatment was suspended. During isolation, deterioration of the patient's condition was observed with psychomotor agitation, bizarre behaviour, and perseverative speech. The patient resumed treatment with ECT, with total remission of the catatonic syndrome and improvement of the affective symptoms. Conclusion(s): Catatonic syndromes are relatively rare, but its association with post-partum depression is not so uncommon. The occurrence of different presentations of catatonia, although described as possible in the same episode in the literature, were not found in any clinical studies reviewed, which leads us to conclude that it is an uncommon situation.

Emerging Catatonia and Psychosis in Resolving COVID-19 Infection in an Adolescent

Introduction: COVID-19 infection may lead to encephalopathy and various neurotrophic effects which can result in neuropsychiatric complications. Here, an asymptomatic adolescent female developed acute onset catatonia and psychosis manifesting during the resolution of Covid-19 infection. Objective(s): Discuss differential diagnosis, medical workup, and initial treatment optimization for acute stabilization. Method(s): This 15-year-old female with no previous psychiatric history nor prodromal symptomatology was hospitalized secondary to Covid -19. During the immediate three-month recovery phase following resolution of Covid-19, the patient exhibited gradually increasing anxiety, paranoia, delusions, disorganized behavior, and weight loss leading to re-hospitalization secondary to catatonia. Negative workup included rapid strep test, urinalysis, chest and abdominal x-ray, EEG, and brain MRI. Lumbar puncture revealed elevated WBC of 18 but was unremarkable for NDMA receptor antibodies, CSF HSV, and encephalitis panel. IV steroids, IVIG, and Anakinra were all given without benefit. Inadequate response to olanzapine, clonidine, and lorazepam led to an Index Series of bilateral electroconvulsive therapy (ECT). Result(s): The provisional diagnosis of psychotic disorder secondary to COVID-19 infection responded robustly regarding sleep, behavior, and affect by session #6, yet positive symptoms of psychosis persist. Ongoing ECT, psychopharmacology, and narrowing of the differential diagnosis continue. Conclusion(s): As more COVID-19 cases evolve during the pandemic, potential post-infectious neuropsychiatric complications should be considered as potentially contributory and kept in a thoughtful differential diagnosis. Regardless of ultimate causation, the acute symptom profile responded robustly to an initial Index Series of ECT.

A Complicated Case of Catatonia

Introduction: Many different causes of catatonia are welldocumented in medicine. Modern understanding of catatonia has evolved in the last 100 years with the suggestion that there is a root cause in neuroinflammation. This is a case report of a young woman who presented to the emergency department with altered mental status, found to have catatonia responsive to lorazepam, with the underlying etiology being a diagnosis of multiple sclerosis. Objective(s): A case-based approach is used to support the following learning objectives: - Review the diagnostic criteria for catatonia - Distinguish between simple and malignant catatonia - Review the Bush-Francis Scale - Review available treatment Methods: Mother brings 24-year-old woman into the hospital for altered mental status and changes in behavior including staring spells, periods of withdrawal, refusal to eat, lack of purposeful movement, apraxia, and mutism that worsened 24 hours prior to presentation. Result(s): The patient was afebile with negative covid-19 test. Recent diagnosis of Bell's palsy treated with antivirals and oral steroird, which terminated just prior to presentation. Additionally, patient had outpatient treatment for vertigo. Lumbar puncture was negative for an infectious process. MRI revealed multiple stable white matter lesions in the periventricular, pontine, and subcortical regions, some oriented perpendicular to the corpus callosum. Conclusion(s): This case of a 24-year-old woman with catatonia brought an opportunity to retrospectively review a case in detail in order to feature learning objectives that review very important considerations in the evaluation, differential diagnosis, symptom tracking, and treatment of catatonia. The future of research in catatonia is bright and diverse.

Treatment of Catatonia in a Young Adult with COVID-19 Infection. Case Report and Review of the Literature on Electroconvulsive Therapy During the Covid-19 Pandemic

Purpose: Infection with COVID-19 has presented diversely in patients, including neuropsychiatric symptoms such as akinetic mutism. Most of these cases involve patients of middle-to-late age or with other health comorbidities. This is a unique case of a long hospitalization for severe catatonic symptoms in a patient with covid-19 infection in which ultimately, ECT helped produce rapid improvements in catatonia. Access to prompt ECT has been limited during the ongoing pandemic, and this case illustrates the importance of managing contamination risk and maintaining access to psychiatric treatment resources. Copyright © 2022

Catatonia Associated With Cerebral Venous Thrombosis in a COVIDPositive Adolescent

BACKGROUND: Catatonia is a psychomotor syndrome characterized by abnormal movements and decreased responsiveness. Diagnosis is made by observing or eliciting at least 3 of the following 12 criteria: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, and echopraxia. It is commonly associated with psychiatric disorders but can also be secondary to a medical condition, more commonly neurologic or metabolic conditions. CASE DESCRIPTION: Patient was a 17-year-old female brought in by her guardian for evaluation at a psychiatric assessment center following a month of regressive behavior and concerns of possible hallucinations. While at the assessment center, the patient began hyperventilating and had 3 seizures. She was transferred to a nearby hospital and continued to seize, becoming hypoxic and requiring intubation. Computed tomography was unremarkable;urine drug testing was positive for THC and benzodiazepines. The patient was transferred to the intensive care unit of a children's hospital. She continued to have poverty of speech, decreased responsiveness, and disorganized behavior after extubation. Child psychiatric services was consulted for these concerns, and differential included psychotic disorder and catatonia, either secondary to psychiatric or medical cause. Patient underwent extensive medical evaluation, which was overall unremarkable, to rule out medical causes (including electroencephalography, cerebrospinal fluid studies, complete blood counts, C-reactive protein, and anti-NMDA antibodies). She did test positive for COVID, which resulted in delay of brain magnetic resonance imaging (MRI) being obtained. She had partial response to lorazepam challenge, and scheduled doses of lorazepam were started after. Bush Francis Catatonia Scale scores did lower partially with scheduled lorazepam, but full resolution of symptoms was not observed. MRI done on day 10 showed findings suspicious for superior sagittal thrombosis. Brain magnetic resonance venography showed superior sagittal and bilateral transverse venous thrombosis. The patient was started on anticoagulation therapy and discharged from hospital with the recommendation of psychiatry and neurology outpatient follow-up. She did not follow up with neurology but did have slow resolution of symptoms per outpatient psychiatry records. DISCUSSION: Catatonia typically results in resolution of symptoms with treatment of underlying cause along with benzodiazepines or electroconvulsive therapy. It is commonly associated with psychiatric disorders, but it is important to evaluate for medical causes as well, especially when there are concerning signs/symptoms. In this patient, there was only a partial response to benzodiazepines, but further improvement with anticoagulation therapy. This along with no previous psychiatric history supports an underlying medical cause. This patient had no history of health conditions associated with hyper-coagulopathies. However, COVID has been associated with risk for arterial and venous thromboembolic complications.

A Case of Cotard Syndrome and Neurosyphilis

BACKGROUND: Cotard syndrome is a rare neuropsychiatric condition in which individuals have delusions of being deceased or losing their organs. It is often seen in patients with severe depression and is associated with catatonia.1 Neurosyphilis is a severe sequelae of untreated treponema pallidum infection in which the paretic form of this disorder commonly has a psychiatric presentation. 2 We present a rare case of Cotard syndrome in a patient with neurosyphilis with successful treatment. OBJECTIVE: To understand Cotard syndrome and underlying neuropsychiatric conditions, and characterize the diagnosis and management of psychiatric symptoms in a patient with neurosyphilis. METHODS: Review of a case using electronic medical records and relevant literature. Key terms searched: 'Cotard syndrome,' 'neurosyphilis,' 'COVID-19 infection' using Medscape and Google Scholar. RESULTS: We present a 49-year-old male with a history of alcohol use disorder in remission, depression, and history of COVID-19 (asymptomatic) 6 months prior. The patient presented to the emergency department for recent changes in behavior. He was agitated, threatening, and required chemical and physical restraint. Evaluation was notable for illogical thought processes with somatic delusions. He repeatedly stated, 'I am already dead, my organs have died,' and had an episode of catatonia. All tests including drug screen and COVID-19 were negative. Rapid plasma regain (RPR) titer was 1:64. Neurology and Infectious Disease were consulted. Lumbar puncture revealed positive venereal disease research laboratory (VDRL) titer of 1:4. The patient was diagnosed with neurosyphilis and major depressive disorder with psychosis with Cotard syndrome. He was treated with intravenous (IV) penicillin G and was discharged on oral mirtazapine 30 mg and olanzapine 20 mg nightly at bedtime, oral donepezil 5 mg daily, thiamine, and folate. CONCLUSIONS: Cotard syndrome is often seen in depression with psychotic features.1 Neurosyphilis can present with depression, anxiety, psychosis, and dementia. Early identification is the key for successful treatment. This is a unique case of neurosyphilis with features of Cotard syndrome in a patient with a history of depression with treatment noncompliance. Studies show that quetiapine and risperidone improve psychosis in neurosyphilis.5 In this case, neurosyphilis was successfully treated with IV penicillin G for 2 weeks. The patient was also tried on antipsychotics and mood stabilizers ' specifically aripiprazole, valproic acid, and haloperidol ' and was eventually stabilized on oral olanzapine 20 mg taken nightly at bedtime. Our differential diagnosis also included COVID-19 delirium with Cotard syndrome, which was ruled out due to a negative COVID test. To our knowledge, there are 2 cases of COVID-19 delirium with Cotard syndrome.6 We present this case to inform clinicians of rare manifestations of neurosyphilis in patients with comorbid psychiatric illness and to advance research into treatment options for psychosis in neurosyphilis.