A 65-year-old woman with a previous diagnosis of bipolar disorder type II was treated with lithium and olanzapine, who came to the emergency department for behavioral changes of four days duration.
The patient had a long history of several psychiatric admissions.
She lives alone and is autonomous for activities of daily living although she receives home help.
The family reports initial symptoms of mood swings and extravagant clothing that subsequently evolves to dysarthria, difficulty walking and temporo-spatial disorientation.
The study carried out in the Emergency Department showed arterial hypertension (174/110 mmHg), hypokalemia (3.09 mEq/l), fever (38.4oC) and urinary dislodgement after urinary catheterization was attributed.
Lithemia, ECG, CK and head CT are normal, as well as plain abdominal and chest X-ray.
Lumbar puncture was performed with normal cell count.
The patient was admitted to the Internal Medicine Department with diagnostic impression of confusional syndrome with no etiology.
It is treated with antipyresis, broad-spectrum antibiotics and prophylaxis of venous thrombosis with heparin.
The study is extended with new lumbar puncture, cranial MRI, thoracic and abdominal-pelvic CT, hemocultive and urocultive that do not present alterations that justify the picture.
The clinical picture evolves in two days to mutism, akinesia, rigidity, distal tremor and decrease of the blink.
Fever and hypertension persist, with hypernatremia (150mEq/l).
Electrolyte disturbances are interpreted in the context of diaphoresis and no ingestion of liquid and food.
After deterioration of the level of consciousness, admission to the resuscitation unit and placement of a nasogastric tube for patient nutrition were evaluated.
Psychiatric evaluation was requested and urgent electroconvulsive therapy (ECT) was prescribed for the next day with diagnostic impression of malignant catatonia.
Two days after the first session, it was found that the patient maintained a coherent spontaneous speech and was fed.
Two more sessions of ECT are administered and lithium is reintroduced.
Fever, diaphoresis, AHT, electrolyte disturbances, and disorientation have been reported.
Herpes virus cultures were negative and encephalitis was ruled out.
The patient was discharged within 30 days with a diagnosis of BAD type II and malignant catatonia.
At discharge the patient was euthymic.
