A case report of cholinergic rebound syndrome following abrupt low-dose clozapine discontinuation in a patient with type I bipolar affective disorder.

BACKGROUND: Rebound cholinergic syndrome is a rare, but well known unwanted phenomenon occurring after abrupt clozapine discontinuation. There have been previous reported cases of cholinergic rebound in the literature; however, these reports described cholinergic rebound following cessation of high doses of clozapine in patients diagnosed with schizophrenia. Here, we report a case of rebound cholinergic syndrome and catatonia in a male patient three days after abrupt discontinuation of 50 mg of clozapine prescribed for type I bipolar affective disorder. CASE PRESENTATION: A 66-year old male of Spanish origin, treated for type I bipolar affective disorder for 15 years and for Crohn disease, was brought to the emergency department because of a sudden onset of mutism, dysphagia and trismus. He was described catatonic and presented hypertension, tachycardia and tachypnea. His body temperature was normal and the laboratory tests were unremarkable at presentation. A head CT and an EEG were in the normal range. While reviewing his history, it appeared the he was on clozapine 50 mg a day, first introduced 2 months ago, during a previous hospitalization for a manic episode resistant to other mood stabilizers. For an unknown reason, the patient's psychiatrist stopped clozapine three days before the admission and replaced it by risperidone 5 mg and quetiapine 200 mg daily. A cholinergic rebound syndrome was then evoked. The patient's ability to speak recovered dramatically and fast after the intravenous administration of 2.5 mg of biperiden supporting the diagnosis. Risperidone and quetiapine were also stopped. The patient fully recovered in 20 days after the reintroduction of 50 mg of clozapine and 2.5 mg of biperiden daily. CONCLUSIONS: This case report underscores that cholinergic rebound syndrome may occur in patients suffering from bipolar affective disorders, being on clozapine as a mood stabilizer. The low dose clozapine does not preclude severe manifestations of the phenomenon. Progressive tapering should therefore be adopted in any case.

Trends and events through seven centuries: the history of a wetland landscape in the Czech Republic.

Environmental change can be viewed as the combined result of long-term processes and singular events. While long-term trends appear to be readily available for observation (in the form of temporal comparisons or space-for-time substitution), it is more difficult to gain information on singular events in the past, although these can be equally significant in shaping ecosystems. We examined the past 700 years in the history of a lowland wetland landscape in the Czech Republic with the help of palaeoecological, ecological, landscape archaeological, and archival data. Macrofossil and pollen data were compared to known drainage works in the area and historical climatological data. Trends and events in habitat conditions were assessed using species indicator values. Results showed that ecological succession was the general process in the study area, detected as a trend towards eutrophication, desiccation and vegetation closure. Short-term events influenced development at the sites mainly from the second half of the 19th century. This is consistent with drainage history, although bias related to sample frequency cannot be excluded. On the whole, long-term trends and discrete events were complementary on different scales. We conclude that humans facilitated and accelerated background processes, which can be most likely associated with the succession of open wetlands towards terrestrial ecosystems.