Deep venous thrombosis of the leg due to psychiatric stupor

Abstract  We report the cases of two patients with psychiatric stupor who developed venous thrombosis. A 29-year-old schizophrenic woman had been hospitalized in psychiatric institutions three times because of stupor associated with auditory hallucinations and thought blocking. These symptoms recurred and she was admitted to our hospital with deep venous thrombosis of her left leg. The other patient was a 67-year-old woman with depression. She had also suffered from insomnia. Following admission to our hospital, she developed a depressive stupor complicated by deep venous thrombosis of her left leg. Both cases were treated with sodium heparin and urokinase, and completely resolved. It is well known that dehydration, infection and decubitus ulcers are important physical complications of psychiatric stupor, but there have been few reports of deep venous thrombosis as a physical complication of stupor.     

Epileptic seizures superimposed on catatonic stupor

PURPOSE: Some patients with nonconvulsive status epilepticus are known to exhibit catatonic stupor. Thus it is necessary to rule out ictal catatonia by electroencephalography in patients with catatonic stupor. However, few reports are available on epileptic seizures superimposed on catatonic stupor. METHODS: We report three cases of epileptic seizures superimposed on psychiatric catatonic stupor without a prominent predisposing factor, including high fever or encephalitis. None of the patients had a personal or family history of neurologic disease, including epilepsy. RESULTS: In all three patients, catatonic stupor persisted after resolution of the epileptic seizures with administration of phenytoin. In two of the three patients, catatonic stupor resolved with electroconvulsive therapy, which caused no marked adverse effects. CONCLUSIONS: Because it is possible that catatonic stupor itself predisposes patients to the development of epileptic seizures, electroencephalographic examinations in patients with catatonic stupor are indispensable for early recognition not only of nonconvulsive status epilepticus but also of epileptic seizures superimposed on catatonic stupor. Electroconvulsive therapy deserves consideration when catatonic stupor persists after resolution of epileptic seizures.     

Pica With Paradichlorobenzene Mothball Ingestion Associated With Toxic Leukoencephalopathy

This is a case report of central nervous system toxicity associated with paradichlorobenzene (PDCB) ingestion. The patient had ingested mothballs composed of 99.99% PDCB for a period of 7 months. She was admitted for depression and had no neurologic symptoms. Later she developed an acute cerebellar syndrome followed by stupor and coma. An extensive workup was negative except for decreasing levels of PDCB in her serum. Imaging revealed a diffuse leukoencephalopathy. Her clinical picture was attributed to PDCB toxicity.     

Hypoglycemic encephalopathy: a case series and literature review on outcome determination

Data on clinical long-term outcome after the acute phase of hypoglycemic encephalopathy (HE) using validated outcome scales is currently unavailable. Here we report the results of a systematic literature search for studies on HE and data on long-term outcome in patients with HE admitted to three Charité hospitals between January 2005 and July 2010. HE was defined as coma/stupor and blood glucose levels?<50?mg/dl on admission, persistence of coma/stupor for?≥24?h despite normalization of blood glucose levels, and exclusion of any other cause of coma/stupor. Outcome was assessed using the modified Rankin scale (mRS), Glasgow Outcome Scale (GOS), and Barthel index (BI). Fifteen patients were included, with a mean age of 60?years (range 29-79). Two were lost to follow-up. Of the remaining 13 patients, six had died (46 %). In the seven survivors, the median mRS score was 0 (range 0-5), median GOS score was 5 (range 2-5), and median BI was 100 (range 0-100). MRIs made in the acute phase were available for three patients and revealed no obvious relation between lesion size or pattern and clinical outcome. To our knowledge, this is the first case series using validated clinical scoring systems to determine clinical long-term outcome after HE. The results suggest that mortality is high, but long-term survival with little or no disability is possible and can be observed in the majority of survivors. Risk of death or poor outcome does not seem to be related to MRI features in the acute phase but rather to other presumably medical factors.     

A Case of Epilepsy Characterized by Spike-Wave Stupor Followed for Long Period

Abstract: A 34-year-old housewife with nonconvulsive status epilepticus was followed up for 20 years since the initial fit. She maintained some contact with reality during the stupor and recalled the episode to some extent, while the EEG showed continuous spike-wave complexes. During the clinical course, the main type of seizures was spike-wave stupor, of which the maximum frequency was several times a week in the hospital and the duration was many minutes to several hours, and also secondarily generalized convulsive seizures occurred approximately once a month. The lasting control of spike-wave stupor was not achieved in spite of the various medications for the long follow-up period. The ictal EEGs of spike-wave stupor always showed the frontal origin. The meaning of the term "nonconvulsive status epilepticus" in this case was briefly discussed.     

Prolonged catatonic stupor successfully treated with aripiprazole in an adolescent male with schizophrenia: a case report

We present the case of a fifteen-year-old adolescent male with schizophrenia who had long-term catatonic stupor and was successfully treated with aripiprazole. The onset of his stupor manifested rapidly after experiencing prodromal symptoms for two months. He was left untreated without adequate food ingestion for three weeks because of his parents' religious faith, and was severely dehydrated and malnourished upon admission to our hospital. After his physical recovery, treatment with risperidone (0.5-2.0 mg, 5 weeks) was started. However, hypersedation occurred, and the risperidone was switched to aripiprazole, with dose increases up to 18 mg/day (5 months). As a result, he recovered from his totally noncommunicative state. Aripiprazole, which has a unique pharmacological mechanism of action distinct from other atypical antipsychotics and an excellent safety profile, may be effective in the treatment of some schizophrenic patients with stupor, which sometimes carries a risk of physical debilitation and requires special attention due to the risk of adverse drug reactions.     

Fatal or severely disabling cerebral infarction during hospitalization for stroke or transient ischemic attack

Summary Six (1%) of 578 patients admitted for cerebral infarction or transient ischemic attack (TIA) suffered a fatal or severely disabling in-hospital cerebral infarction following a period of stabilization or improvement lasting more than 1 day. These infarctions were characterized by the sudden onset of stupor or coma and subsequent development of transtentorial herniation due to carotid or middle cerebral artery territory infarction, or widespread brain-stem infarction due to basilar occlusion. Only one patient survived. Four patients had largevessel disease documented by Doppler, angiography, or at autopsy. Each of these six infarcts occurred during the morning hours, 4–9 days after the initial event, 3–8 days after initiation of intravenous heparin, and within 4–8 h after intravenous heparin had been discontinued. No coagulation abnormalities were documented. We believe that these cases indicate that among patients admitted for cerebral infarction or TIA, fatal or severely disabling in-hospital cerebral infarction after a period of stabilization or improvement may occur in patients having an initially mild to moderate clinical deficit, that those suffering large artery disease may be at greater risk, and that there may be a relationship between heparin withdrawal and cerebral infarction in some patients.Supported in part by the Sunny von Bulow Coma and Head Trauma Research Foundation     

Inpatient alcoholics: characteristics and needs

Studies of the incidence and prevalence of alcoholism admissions have demonstrated repeatedly the large numbers of alcoholics treated as inpatients. In most reports, alcoholism is one of the two or three diagnostic categories with the largest number of psychiatric admissions.^{1, 2} In these reports, first admissions for alcoholism comprised from 10% to 20% of the total first admissions for all psychiatric disorders.In spite of the large numbers of patients admitted for this disorder, relatively little is known about the epidemiology of their clinical characteristics. Clinical information of this kind is crucial because it provides essential data about several major issues important for program planning. Two of these issues are: (1) whether alcoholic inpatients are hospitalized for severe medical or psychiatric problems or are primarily admitted for disposition “just for a place to stay” and (2) whether these patients are socially bereft and totally dependent on the treatment facilities for care and rehabilitation or have other support systems available that can be of use.Data on the chronicity and severity of disorders in alcoholics admitted for treatment and on the social resources of these patients are crucial for resolving these issues. Information is also needed regarding the kinds of patients treated in different facilities in order to evaluate problems that might arise from disproportionate distribution of patients to treatment centers.This report provides clinical and epidemiological information in these areas by describing the prevalence, incidence, and demographic characteristics of all alcoholics from a given catchment area admitted as inpatients over a period of 1 year, by evaluating the clinical characteristics of the incidence group through a review of their case records, and by determining the kinds of patients treated in the different facilities.     

Abnormalities of peripheral nerve conduction in relation to thiamine status in alcoholic patients

Thiamine status was evaluated using the erythrocyte transketolase activation assay in 20 alcoholic patients admitted on a voluntary basis to a Detoxification Unit. Electromyographic evaluation revealed significant reductions of motor and sensory conduction velocities in the alcoholic group. 38% of alcoholic patients showed significant erythrocyte transketolase activation deficits indicative of severe thiamine deficiency. In the case of peroneal nerve, reduced conduction velocities were negatively correlated with abnormal transketolase parameters. These findings are consistent with a contributory (but not exclusive) role of thiamine deficiency in the pathogenesis of alcoholic peripheral neuropathy. Deficiencies of other vitamins as well as direct neurotoxic effects of alcohol could also be involved in this phenomenon.     

Clozapine withdrawal symptoms in a Parkinson's disease patient.

Abrupt clozapine withdrawal can cause rebound psychosis and severe somatic symptoms in psychiatric patients. We report on the case of an advanced Parkinson's disease patient who developed myoclonus, tremor, rigidity, hyperreflexia, and stupor after abrupt clozapine withdrawal. The patient's symptoms resolved with treatment with cyproheptadine. This clinical picture suggests serotonergic rebound as an explanation for the patient's symptoms, although other pharmacological mechanisms are possible. Clozapine should be gradually withdrawn over a period of 1 to 2 weeks when possible, and abruptly discontinued only when necessary.     

Modafinil in endozepine stupor. A case report

BACKGROUND: Endozepine-4 stupor is a rare disorder. It presents with recurrent episodes of stupor and coma. Endozepine-4 levels are elevated during an attack with electroencephalogram showing fast activity during the ictal phase. There is no specific treatment and various drugs have been tried without long-term benefit. METHOD: We used the vigilance promoting drug modafinil to prevent such attacks in a case presented with endozepine stupor. RESULTS: The vigilance promoting drug modafinil prevented recurrent episodes of stupor and coma in this patient at a dose of 200 mg/day for a period of six months. Upon withdrawal of the drug, the patient experienced recurrent episodes and on reinstitution of modafinil she has remained asymptomatic in the following one year.     

Stupor Following Administration of Valproic Acid to Patients Receiving Other Antiepileptic Drugs

Stupor is an unusual complication following the addition of valproic acid to other antiepileptic drugs. We report four such cases. Stupor occurred acutely in 3 patients and insidiously in the fourth. In the cases of acute toxicity, neither toxic levels of valproate nor significant elevations in blood levels of the other drugs occurred. In the fourth patient, stupor occurred concomitantly with a rise in the phenobarbital level. The electroencephalograms of all 4 patients revealed generalized high-amplitude rhythmic bisynchronous delta activity. Recovery occurred following discontinuation of valproic acid or other antiepileptic drugs. These observations suggest that stupor may occur as a result of drug interactions after the addition of valproic acid to other antiepileptic drugs.     

精神科急性入院患者中紧张症的识别和治疗

目的回顾性分析精神科急性入院患者中紧张症的识别和治疗情况。方法对2017年10月1日至2018年10月1日我院重症精神病房急性入院患者1020例的病历资料进行回顾性分析,根据《美国精神障碍诊断与统计手册第5版》(Diagnostic and Statistical Manual of Mental Disorders,5th Edition,DSM-5)紧张症的诊断标准进行诊断,参照Bush-Francis紧张症评定量表(Bush-Francis catatonia rating scale,BFCRS)的症状定义归类确诊病例的临床表现,并比较不同治疗方案的疗效。结果确诊紧张症91例,占调查患者的8.92%。81例(89.01%)紧张症患者的基础疾病为精神分裂症。患者最常见的紧张症症状为缄默(81.32%)、兴奋(72.53%)、冲动性(71.43%)、静止/呆滞(65.93%)和作态(51.65%),另外先占观念(92.30%)和怪异念头(58.24%)也较常见。仅有7例(7.69%)患者的病历资料中曾提及“(亚)木僵”、“紧张症/综合征”等词。30例患者仅用抗精神病药治疗,治愈率为83.33%(25例),仅用抗精神病药治疗者与抗精神病药联合苯二氮 类和/或改良电休克治疗者的治愈率差异无统计学意义(X^2=1.75,P=0.63)。1例患者在肌注氟哌啶醇后出现恶性综合征。结论精神科急性入院患者中紧张症并不少见,但识别率低。抗精神病药能有效治疗紧张症,但存在出现恶性综合征的风险。     

Is stupor by itself a catatonic symptom?

Many patients present with stupor or substupor without classical catatonic signs as described by Kahlbaum. The phenomenological literature is not clear as to whether stupor, when it presents alone, constitutes a separate syndrome or is a forme fruste of catatonia. All patients who presented with stupor, (a) partial or total mutism or (b) absent or decreased motor responses (n = 22), were compared with patients who also had classical catatonic signs such as negativism or waxy flexibility (n = 43) over a one-year period (1988), on sociodemographic and clinical variables. There were very few significant differences between the two groups (age, sex, diagnosis, duration of illness, number of ECTs required). The stupor group had a slight excess of patients with manic-depressive psychosis, depression and more frequently positive family histories of mental illness. The current study provides a tentative support to the hypothesis that stupor is a catatonic sign, and even when present alone can be considered to constitute a catatonic syndrome.     

Which patient fares worse after early deterioration due to swelling from hemispheric stroke?

The authors studied 24 patients admitted to the neurointensive care unit because of clinical deterioration to drowsiness or stupor and midline shift after complete middle cerebral artery infarction (coMCAI) stroke. Fourteen (58%) experienced further deterioration and either underwent hemicraniectomy or refused surgery and died. These patients were significantly more likely to be female (72% vs 20%) and to have additional vascular territorial infarction (72% vs 0%) on initial CT. These features may help to identify patients at high risk for further deterioration after coMCAI.     

CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study

Computed tomography was performed on 1,378 patients admitted within 3 days of subarachnoid hemorrhage (SAH) at 71 centers in a cooperative study. CT on the day of SAH (day 0) was abnormal in 95.8%. Intracranial blood was detected in 95.3% of patients on day 0, 90.5% on the first day after SAH (day 1), and 73.8% on day 3. CT was normal in only 1 of 284 patients in stupor or coma but was normal in 14.6% of 638 alert patients. In the first few days after SAH, CT is highly accurate, often obviating the need of CSF examinations. The interval from SAH until CT and the seriousness of the patient's condition are two factors that influence the results of CT.     

Acute and long-term treatment of catatonia with risperidone

Catatonia is a rare but difficult-to-treat disorder. Here, we report on the case of a schizophrenic patient who developed several episodes of severe catatonia after suffering from adequately treated Lyme disease with encephalitis. The catatonic stupor was not responsive to typical neuroleptics and benzodiazepines. After the medication was changed to risperidone, there was a dramatic and persistent improvement of the patient's condition. Two relapses during the follow-up period over five years were caused by dose reductions. Risperidone might be a promising drug in the treatment of acute catatonia and in preventing further episodes.     

Catatonia. A prospective clinical study.

We studied 55 patients admitted during 14 months to two inpatient psychiatric units of a municipal hospital who exhibited one or more of the catatonic signs of mutism, stereotypy, posturing, catalepsy, automatic obedience, negativism, echolalia/echopraxia, or stupor. Only four of the 55 patients satisfied our research criteria for schizophrenia, whereas over two thirds had diagnosable affective disorders, usually mania. The eight catatonic motor signs were nonspecific and homogeneously distributed among the various research diagnostic groups, with the number and type of individual signs unrelated to short-term treatment outcome. A favorable treatment response was shown for the entire catatonic sample, with two thirds markedly improved or in remission at the time of discharge. These findings are consistent with those of other investigators of the catatonic syndrome for the past 100 years.     

Recurrent stupor due to lysinuric protein intolerance

Recurrent stupor in children is an uncommon clinical problem with a wide differential diagnosis; inherited metabolic disorders account for a vast majority. We report a 9-year-old girl with recurrent episodes of stupor. Initial episode was treated as viral encephalitis and the second episode was managed as non-convulsive status epilepticus. Hyperammonemia was detected in the last episode. Metabolic work-up after dietary protein challenge revealed classical biochemical features of lysinuric protein intolerance. She was managed with protein-restricted diet, which resulted in marked neurological improvement. LPI is a rare inherited metabolic disorder due to membrane transport defect of cationic amino acids.     

A case of adult-onset spike-wave stupor associated with hypoparathyroidism and hyperostosis frontalis interna (HFI)

A 34-year-old women without history of seizures was admitted to our hospital because of the diminished responsiveness and the repeated blinking for two days. Her past history showed neither surgery nor inflammation of the thyroid gland. General physical examination was normal. On neurological examination, the patient was blinking frequently and staring without any responsiveness. However, she occasionally became able to respond correctly to verbal orders, such as "open your eyes", "open your mouth", "stand up" and so on, which occurred abruptly just like the switch-on. She was otherwise normal neurologically. The laboratory data showed hypocalcemia, hyperphosphatemia, decreased level of parathyroid hormone and normal renal function, indicating the presence of idiopathic hypoparathyroidism. EEG showed the continuous generalized 2-4 Hz spike and wave complexes with the maximum intensity on frontal lobes. Skull roentgenograms and MRI CT of the head disclosed hyperostosis frontalis interna (HFI) and the compression of superior medial frontal lobes by the HIF. SPECT also showed the diminished circulation and hypometabolism in the superior frontal lobes. Based on clinical and EEG findings, the diagnosis of spike-wave stupor was made. She was successfully treated with valproic acid and ethosuximide. Spike and wave complexes on EEG completely disappeared after administration of alfacalcidole. It is assumed that both hypoparathyroidism and HFI were deeply involved in the development of spike-wave stupor in this adult case.