Abstract
Case report
A 51-year-old Burmese woman with no family or personal history of psychiatric disorders was admitted to the Critical Care Unit (CCU) following an anterior resection for metastatic (lung and hepatic) adenocarcinoma of the sigmoid colon. Postoperatively there were two initial complications: first, an episode of rectal bleeding from the anastomosis site, necessitating a return to theatre for exploration only; second, an episode of pulmonary oedema, during which there were no prolonged periods of hypoxaemia, and which resolved following non-invasive continuous positive airway pressure ventilation. On return to CCU, the patient showed no signs of delirium, was oriented in time, place and person, and was communicating appropriately.
Subsequently, eight hours after returning from theatre her Glasgow Coma Scale fell from 15 to 6 (E1M4V1), with no obvious focal neurological abnormality. Blood tests (i.e. full blood profile, liver function tests, urea and electrolytes) and arterial blood gases revealed no cause for this deterioration. Accordingly, she was intubated and ventilated, and a head CT scan was performed which revealed no apparent abnormalities to explain her deterioration. She regained a full level of consciousness the next day. Then, however, her level of consciousness progressively dropped over several hours. On examination, she kept her eyelids clenched, and it was impossible to assess her pupils, which rolled backwards on manual eyelid retraction. Otherwise, cranial nerve examination was entirely normal, including a good gag reflex. Assessment of upper and lower limb neurology was equally unremarkable with down-going plantar responses.
A Bi-Spectral (BIS) monitor (routinely used to monitor intra-operative conscious levels) was employed to assess EEG activity and level of consciousness, as no electroencephalogram could be immediately arranged. This demonstrated a bispectral index of 85–90, which is associated with wakefulness, and not any major intra-cerebral event or convulsive activity. 1
Over the course of the next 6 days, further drops in consciousness coincided with repeated episodes of minor rectal bleeding of altered blood, which did not require further investigation or treatment (they were not associated with a decrease in haemoglobin level or cardiovascular compromise). Again, repeated neurological examinations and investigations including a lumbar puncture and head MRI scan excluded an organic cause for her symptoms. Having excluded any possible organic aetiology, we began to investigate and treat inorganic causes.
During latter episodes of reduced consciousness, we noted signs of waxy flexibility (patient retained limb positions passively imposed during examination), stupor (marked hypokinesia), negativism (resistance to instructions), echolalia (speech of the examiner was copied with modification and amplifications) and echopraxia consistent with a diagnosis of catatonia (ICD 10).
Catatonia corresponds to a psychomotor phenomenon that may be primarily psychiatric or secondary to a general medical condition. 2 We propose that in our patient's case, it was a reactive response to severe psychological stress from multiple factors, namely cancer diagnosis, shortened life prognosis, surgery, postoperative complications, recurrent rectal bleeds and prolonged CCU admission. The only reported postoperative cases of catatonia have been directly related to liver transplantation. 3 Apart from being postoperative, these cases share no other similarities with our patient.
On day five of her stay in CCU, we commenced treatment with the atypical anti-psychotic drug Risperidone (1mg BD) with a dramatic improvement in our patient's mental state and she was discharged to the ward two days later. Such a rapid response has been described in several case studies, and large clinical trials to support the neuroleptic treatment of catatonia are awaited. 4, 5 She had no further episodes of catatonia.
A diagnosis of catatonia should be considered in critically-ill patients with unexplained motor, behavioural and/or psychotic symptoms. BIS monitoring is a useful adjunct to clinical suspicion in making the diagnosis, particularly in an environment where a neurological opinion and investigations cannot easily be sought.
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