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Tsai PS, Chen Y, Chen SY, Hsu CY, Wu JE, Lee CC, Chan TM. Plasmapheresis for a Patient with Catatonia and Systemic Lupus Erythematosus: A Case Report and Literature Review. J Clin Med 2022; 11:jcm11226670. [PMID: 36431144 PMCID: PMC9692717 DOI: 10.3390/jcm11226670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Neuropsychiatric systemic lupus erythematous (NPSLE) encompasses various psychiatric and neurological manifestations that develop in patients with systemic lupus erythematous (SLE), secondary to the involvement of the central nervous system (CNS). Although neuropsychiatric manifestations are commonly described in NPSLE, catatonia has been less frequently reported in patients with SLE. The roles of benzodiazepines (BZDs), immunosuppression, therapeutic plasma exchange (TPE), and electroconvulsive therapy (ECT) have all been reported in the management of catatonia. Furthermore, another research reported that catatonic symptoms associated with NPSLE were considerably improved by TPE. We, herein, report a case of catatonia in a patient with newly diagnosed NPSLE who exhibited a favorable prognosis through the early initiation of systemic immunosuppressants and TPE. Furthermore, we have reviewed the literature on the role of medication and plasmapheresis (PP), or TPE, in the treatment of catatonia that is associated with SLE.
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Affiliation(s)
- Pei-Shan Tsai
- Taipei Tzu Chi Hospital, Division of Gastroenterology, New Taipei City 231, Taiwan
| | - Yu Chen
- Division of Rheumatology, Allergy and Immunology, New Taipei Municipal Tucheng Hospital, Chang Gung Memorial Hospital, New Taipei City 236, Taiwan
| | - Shou-Yen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Kaohsiung City 833, Taiwan
| | - Jiao-En Wu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Chih-Chun Lee
- Department of Medical Education, Chang Gung Memorial Hospital, Keelung Branch, Keelung City 204, Taiwan
| | - Tien-Ming Chan
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Linkou Branch, Chang Gung University, Taoyuan City 333, Taiwan
- Correspondence: ; Tel.: +886-97536-6029
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Luccarelli J, Kalinich M, McCoy TH, Fernandez-Robles C, Fricchione G, Smith F, Beach SR. The occurrence of catatonia diagnosis in acute care hospitals in the United States: A national inpatient sample analysis. Gen Hosp Psychiatry 2022; 77:141-146. [PMID: 35660679 PMCID: PMC9301762 DOI: 10.1016/j.genhosppsych.2022.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/06/2022] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Catatonia is a neuropsychiatric disorder that can occur in the setting of many illnesses, but the frequency of catatonia diagnosis among hospitalized patients is poorly characterized. This study reports the occurrence of catatonia diagnosis among acute care hospital discharges in the United States and the cooccurring diagnoses of these patients. METHOD The National Inpatient Sample, an all-payors database of acute care hospital discharges, was queried for patients older than 18 discharged with a diagnosis of catatonia in 2019. RESULTS 13,630 encounters among the 30,080,038 adult hospitalizations in the NIS during the study year included a diagnosis of catatonia. Total hospital charges for these admissions were $1.15 billion, with 215,165 cumulative hospital days. In this sample, approximately 60% of admissions had a primary psychiatric discharge diagnosis, while 40% had a primary neurologic or medical discharge diagnosis. Procedures were performed in 36.7% of hospitalizations involving catatonia, of which electroconvulsive therapy was most common. CONCLUSIONS Catatonia is a rare but costly discharge diagnosis among patients in acute care hospitals. It occurs across the age spectrum and is associated with a range of medical and psychiatric comorbidities. Further research is needed to better characterize the occurrence of catatonia and its optimal treatment.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Mark Kalinich
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Thomas H. McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Carlos Fernandez-Robles
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Gregory Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Felicia Smith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Scott R. Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Beil EF, Vora SS. Malignant Catatonia After Antipsychotic and High-Dose Steroid Use in a Teenager With Neuropsychiatric Systemic Lupus Erythematosus. J Clin Rheumatol 2021; 27:S394-S395. [PMID: 32658046 DOI: 10.1097/rhu.0000000000001481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Catatonia in systemic lupus erythematosus: case based review. Rheumatol Int 2021; 42:1461-1476. [PMID: 34580753 DOI: 10.1007/s00296-021-05006-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
Catatonia is a rare psychomotor syndrome characterized by stupor, posturing and echophenomena. It can be associated with schizophrenia, infections, drugs and autoimmune causes like anti N-methyl D-aspartate (NMDA) receptor encephalitis and systemic lupus erythematosus (SLE). Here we report two cases of systemic lupus erythematosus with catatonia, who improved with immunosuppressive treatment and review the cases described in the literature. The first case presented with fever, pancytopenia, toxic epidermal necrolysis (TEN)-like rash and later developed catatonia and macrophage activation syndrome (MAS). The second case presented with acute cutaneous lupus erythematosus (ACLE), fever, alopecia, polyarthralgias, nephritis, cytopenias along with catatonia. Successful management of this syndrome requires prompt recognition and treatment with immunosuppression as well as benzodiazepines with or without electroconvulsive therapy (ECT).
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Fricchione G, Beach S. Cingulate-basal ganglia-thalamo-cortical aspects of catatonia and implications for treatment. HANDBOOK OF CLINICAL NEUROLOGY 2019; 166:223-252. [PMID: 31731912 DOI: 10.1016/b978-0-444-64196-0.00012-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The catatonic syndrome is an example of a multifactorial neurobehavioral disorder that causes much morbidity and mortality but also has the potential to unlock the mystery of how motivation and movement interact to produce behavior. In this chapter, an attempt is made to understand better the catatonic syndrome through the lens of neurobiology and neuropathophysiology updated by recent studies in molecular biology, genomics, inflammasomics, neuroimaging, neural network theory, and neuropsychopathology. This will result in a neurostructural model for the catatonic syndrome that centers on paralimbic regions including the anterior and midcingulate cortices, as they interface with striatal and thalamic nodes in the salience decision-making network. Examination of neurologic disorders like the abulic syndrome, which includes in its extreme catatonic form, akinetic mutism, will identify the cingulate cortex and paralimbic neighbors as regions of interest. This exploration has the potential to unlock mysteries of the brain cascade from motivation to movement and to clarify catatonia therapeutics. Such a synthesis may also help us discern meaning inherent in this complex neurobehavioral syndrome.
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Affiliation(s)
- Gregory Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Scott Beach
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Boeke A, Pullen B, Coppes L, Medina M, Cooper JJ. Catatonia Associated With Systemic Lupus Erythematosus (SLE): A Report of Two Cases and a Review of the Literature. PSYCHOSOMATICS 2018; 59:523-530. [PMID: 30270156 DOI: 10.1016/j.psym.2018.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is known to cause neuropsychiatric symptoms (NPSLE). While not formally recognized as a syndrome associated with NPSLE, catatonia has frequently been reported. OBJECTIVE It is important for clinicians to recognize and treat catatonia as a potential manifestation of NPSLE. We present 2 cases of SLE with catatonia and review the cases reported in the literature. METHODS We performed a PubMed search for reported cases of catatonia in SLE. Case reports that met Diagnostic and Statistical Manual of Mental Disorders-5th ed. diagnostic criteria for catatonia were summarized to assess common diagnostic tests and treatments. RESULTS Twenty-six articles describing a total of 35 patients (all female), in addition to our 2 patients, were included in the report. All but one of the patients received immunosuppressive therapy for treatment of SLE. To treat catatonia symptoms, 81% of the patients received benzodiazepines, and 38% received electroconvulsive therapy. CONCLUSIONS Catatonia can be a manifestation of NPSLE, particularly in the presence of serologies and symptoms indicative of an active lupus flare. Management of catatonia involves management of the underlying condition, in this case immunomodulatory treatments for NPSLE; avoidance of treatments, such as antipsychotics, which can worsen catatonia; and symptomatic treatments for catatonia, for which benzodiazepines are a first-line treatment, and electroconvulsive therapy when catatonia is refractory to benzodiazepines.
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Affiliation(s)
- Annabel Boeke
- Department of Psychiatry (A.B.), NewYork-Presbyterian Hospital, New York, NY
| | - Bianca Pullen
- Department of Psychiatry (A.B.), NewYork-Presbyterian Hospital, New York, NY
| | - Lucas Coppes
- Department of Psychiatry (A.B.), NewYork-Presbyterian Hospital, New York, NY
| | - Michel Medina
- Department of Psychiatry (A.B.), NewYork-Presbyterian Hospital, New York, NY
| | - Joseph J Cooper
- Department of Psychiatry (A.B.), NewYork-Presbyterian Hospital, New York, NY.
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Assess the etiologies associated with catatonia in children and adolescents• Evaluate the differential diagnosis of pediatric catatonia• Interpret the literature regarding the treatment of children and adolescents with catatonia OBJECTIVE: Pediatric catatonia is associated with many medical and psychiatric conditions. Mortality is high, and proper treatment can be lifesaving. Catatonia is increasingly recognized in pediatric populations, in which about 20% of cases are related to underlying medical conditions. To minimize morbidity, clinicians must rule out underlying disorders while simultaneously managing symptoms and causes. In our review we discuss (1) recommendations to aid rapid decision making, both diagnostic and therapeutic, (2) emergent conditions and management, (3) disorders associated with pediatric catatonia, including developmental, acquired, idiopathic, and iatrogenic etiologies, (4) available treatments, and (5) medicolegal considerations. METHODS Initial PubMed search without date constraints using MeSH terms related to pediatric catatonia, with subsequent searches on pertinent subtopics using PubMed and Google Scholar. RESULTS Pediatric catatonia is a dangerous but treatable neuropsychiatric condition. Psychiatrists need to be aware of differential diagnoses and to be able determine appropriate treatment within a short time frame. With prompt diagnosis and treatment, outcomes can be optimized. CONCLUSION Pediatric catatonia is underdiagnosed and requires rapid evaluation and management.
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Lalanne L, Meriot ME, Ruppert E, Zimmermann MA, Danion JM, Vidailhet P. Attempted infanticide and suicide inaugurating catatonia associated with Hashimoto's encephalopathy: a case report. BMC Psychiatry 2016; 16:13. [PMID: 26786766 PMCID: PMC4719733 DOI: 10.1186/s12888-016-0719-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/15/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Catatonia is a neuropsychiatric syndrome with motor and behavioural symptoms. Though usually occurring in patients with schizophrenia and mood disorders, this syndrome may also be associated with neurological diseases or general medical conditions. Few cases of catatonia associated with autoimmune disorders have been described. CASE PRESENTATION Here, we report the case of a 27-year-old woman diagnosed with Hashimoto's encephalitis (HE) who attempted suicide and infanticide by defenestration. As she presented risk factors for postpartum psychosis, she was treated principally with antipsychotics. Despite adequate treatment for psychosis, symptoms worsened and she developed catatonia. Complementary investigations showed elevated titres of anti-thyroglobulin and anti-thyroperoxidase antibodies (200 and 10 times, respectively, as compared to normal levels) and electroencephalography were suggestive of encephalopathy. In the presence of an otherwise unexplained neuropsychiatric condition, HE was suspected and oral prednisolone was introduced. Psychiatric symptoms improved dramatically within 72 h and the patient was still free of any symptom 3 years later. CONCLUSION Catatonia of organic aetiology should always be considered before a psychiatric aetiology especially in case of clinical worsening in spite of adequate psychotropic treatment. To our knowledge, this is the first description of catatonia associated with HE.
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Affiliation(s)
- Laurence Lalanne
- Department of Psychiatry, Fédération de Médecine Translationelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France. .,INSERM 1114, Fédération de Médecine Translationelle de Strasbourg, University Hospital of Strasbourg, Strasbourg, France. .,INSERM1114-Department of Psychiatry, University of Strasbourg- 1 place de l'hôpital, 67000, Strasbourg, France.
| | - Marie-Emmanuelle Meriot
- Department of Psychiatry, Fédération de Médecine Translationelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France.
| | - Elisabeth Ruppert
- Department of Neurology, Sleep and Electrophysiology Clinic, Fédération de Médecine Translationelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France. .,Institute for Cellular and Integrative Neurosciences, CNRS - UPR 3212, Fédération de Médecine Translationelle de Strasbourg (FMTS), 67084, Strasbourg, France.
| | - Marie-Agathe Zimmermann
- Department of Psychiatry, Fédération de Médecine Translationelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France.
| | - Jean-Marie Danion
- Department of Psychiatry, Fédération de Médecine Translationelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France. .,INSERM 1114, Fédération de Médecine Translationelle de Strasbourg, University Hospital of Strasbourg, Strasbourg, France.
| | - Pierre Vidailhet
- Department of Psychiatry, Fédération de Médecine Translationelle de Strasbourg (FMTS), University Hospital of Strasbourg, Strasbourg, France. .,INSERM 1114, Fédération de Médecine Translationelle de Strasbourg, University Hospital of Strasbourg, Strasbourg, France.
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Hussain A, Mir TH, Dar MA, Naqashbandi JI, Hussain T, Bashir A, Shah MS, Mushtaq R, Saleem B. Systemic Lupus Erythematous Presenting as Catatonia and its Response to Electroconvulie Therapy. Indian J Psychol Med 2015; 37:456-9. [PMID: 26702183 PMCID: PMC4676217 DOI: 10.4103/0253-7176.168597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neuropsychiatric systemic lupus erythematous (SLE) encompasses various psychiatric and neurological manifestations that develop in SLE patients, secondary to involvement of central nervous system. Neuropsychiatric SLE, presenting as catatonia is very uncommon, and treatment of this condition is not well defined. Previously the role of benzodiazepines, immunosuppression, plasma exchange, and electroconvulsive therapy (ECT) has been described in its management. Here we describe a case of neuropsychiatric lupus presenting as catatonia that did not respond to benzodiazepines or immunosuppression. The symptoms of catatonia showed improvement with ECT. Furthermore, we have discussed the pathology of the disorder and the role of ECT in the treatment of cases of catatonia associated with SLE, who do not respond to benzodiazepines.
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Affiliation(s)
- Arshad Hussain
- Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Tajamul H Mir
- Department of Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Mansoor Ahmad Dar
- Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
| | | | - Tajamul Hussain
- Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Anam Bashir
- Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Majid Shafi Shah
- Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Raheel Mushtaq
- Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Basharat Saleem
- Department of Anesthesia, Government Medical College, Srinagar, Jammu and Kashmir, India
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Kusztal M, Piotrowski P, Mazanowska O, Misiak B, Kantorska-Janiec M, Boratyńska M, Klinger M, Kiejna A. Catatonic episode after kidney transplantation. Gen Hosp Psychiatry 2014; 36:360.e3-5. [PMID: 24559791 DOI: 10.1016/j.genhosppsych.2014.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 12/30/2013] [Accepted: 01/07/2014] [Indexed: 11/16/2022]
Abstract
There is a growing body of case reports of catatonic symptoms after organ transplantations. A considerable number of these cases might be attributed to neurotoxicity induced by immunosuppressive medications. However, the etiology of other cases remains unclear. We present the case of a 21-year-old woman who developed catatonia after kidney transplantation from a deceased donor. In this case, nontoxic tacrolimus levels were found, and other causal factors including infections, uremia or transplant rejection were excluded. Electroconvulsive therapy followed by olanzapine proved to be effective treatment.
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Affiliation(s)
- Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland.
| | | | - Oktawia Mazanowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Błażej Misiak
- Department of Psychiatry, Wroclaw Medical University, Poland; Department of Genetics, Wroclaw Medical University, Poland
| | | | - Maria Boratyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Andrzej Kiejna
- Department of Psychiatry, Wroclaw Medical University, Poland
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Leon T, Aguirre A, Pesce C, Sanhueza P, Toro P. Electroconvulsive therapy for catatonia in juvenile neuropsychiatric lupus. Lupus 2014; 23:1066-8. [PMID: 24786782 DOI: 10.1177/0961203314533603] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Neuropsychiatric manifestations are serious and frequent complications of systemic lupus erythematous (SLE). Catatonia is a neuropsychiatric disorder characterized by motor disturbance (including waxy flexibility and catalepsy), stupor, excitement, negativism, mutism, echopraxia and echolalia. Catatonia associated with SLE has been only rarely reported, especially in children. Here we present a case of a 14-year-old patient encountered in consultation-liaison psychiatry who presented catatonia associated with SLE. Her catatonia was refractory to treatment with pulse methylprednisolone, intravenous cyclophosphamide and rituximab. The patient responded to a combined therapy of electroconvulsive therapy and benzodiazepines. The present case suggests that although rarely reported, catatonia seen in the background of SLE should be promptly identified and treated to reduce the morbidity.
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Affiliation(s)
- T Leon
- Section of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Department of Psychiatry, Faculty of Medicine, Pontifícia Universidad Católica de Chile, Chile
| | - A Aguirre
- Section of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Department of Psychiatry, Faculty of Medicine, Pontifícia Universidad Católica de Chile, Chile
| | - C Pesce
- Section of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Department of Psychiatry, Faculty of Medicine, Pontifícia Universidad Católica de Chile, Chile
| | - P Sanhueza
- Section of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Department of Psychiatry, Faculty of Medicine, Pontifícia Universidad Católica de Chile, Chile
| | - P Toro
- Section of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Department of Psychiatry, Faculty of Medicine, Pontifícia Universidad Católica de Chile, Chile
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Grover S, Singh A, Sarkar S, Bhalla A. SLE presenting with catatonia in an adolescent girl. J Pediatr Neurosci 2014; 8:262-3. [PMID: 24470834 PMCID: PMC3888057 DOI: 10.4103/1817-1745.123715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aakanksha Singh
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Siddharth Sarkar
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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