Catatonia Associated With Cerebral Venous Thrombosis in a COVIDPositive Adolescent

ABSTRACT

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.