Therapeutic strategies for catatonia in paraneoplastic encephalitis

Abstract

This report is about a 40-year-old man suffering from fluctuating catatonia as main symptom of long-lasting paraneoplastic encephalitis caused by a testicular neoplasm. With recurrence of a neoplasm initially diagnosed as seminoma after a 7-year symptom-free interval the patient suddenly developed various neurological and psychopathological symptoms including seizures, autonomic dysregulation, continuous anterograde short-term amnesia and predominantly a long-lasting complex catatonic syndrome with on-off phenomena. Repeated MRI scans of the brain showed no pathology; brain FDG-PET scans indicated a hypometabolism of the frontal cortex and the left temporal lobe. Eventually a paraneoplastic encephalitis was diagnosed. Repeated resections of tumour recurrences and plasmapheresis moderately alleviated catatonic symptoms. Haloperidol and lorazepam effectively relieved catatonic symptoms in contrast to various atypical antipsychotic drugs and diazepam. A series of 12 electroconvulsive treatments (ECT) temporarily improved residual catatonic symptoms such as catalepsy, stupor and mutism. Further neoplasm recurrences, however, reinforced catatonia until the tumour was successfully treated and the patient fully recovered. This case report illustrates the potential but also the limitations of various therapeutic approaches in organic catatonia due to paraneoplastic encephalitis.

Rediscovering catatonia: the biography of a treatable syndrome

“…By September 2011, 68 reports are listed with 2 coauthored by Josef Dalmau; by February 2012, the number has increased to 126 with 32 by Dalmau; and by October 24, 2012 the number of reports had increased to 166 with 40 co-authored by Dalmau. Considering these cases as examples of catatonia is verified by the reported efficacy of ECT, cited in reports in five patients (194)(195)(196)(197). The initial references to anti-NMDAR encephalitis cited in PubMed are dated 2007.…”

“…The initial references to anti-NMDAR encephalitis cited in PubMed are dated 2007. By September 2011, 68 reports are listed with 2 coauthored by Josef Dalmau; by February 2012, the number has increased to 126 with 32 by Dalmau; and by October 24, 2012 the number of reports had increased to 166 with 40 co-authored by Dalmau. Considering these cases as examples of catatonia is verified by the reported efficacy of ECT, cited in reports in five patients (194)(195)(196)(197). One example is described (198): year-old girl became uncooperative, confused, and agitated with slurred speech and hallucinations after an upper respiratory tract infection.…”

Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment

“…There is a dearth of information regarding management of psychiatric and behavioral symptoms, including agitation, anxiety, mood dysregulation, depression, disorganized thinking, paranoid ideation, and hallucinations. Some attention has been given to the use of ECT as a means of targeting catatonic presentations in patients with autoimmune encephalitis (16)(17)(18). What information can be gleaned from the available literature is often mentioned in passing as part of the case description.…”

Some patients with advanced malignancies also have reversible catatonia or limbic encephalitis

“…For example, a patient with limbic encephalitis associated with recurrent metastatic seminoma actually presented with catatonia responsive to lorazepam but also to prednisone, intravenous immunoglobullin (IVIG) and plasmapheresis. 23 In that patient's case, catatonia and encephalitis recurred with tumor recurrence and resolved completely with treatment of the underlying malignancy. 23 It is thought that anti-NMDA receptor encephalitis has catatonia as the single most common clinical presentation, up to 50% of cases.…”