Progressive multifocal leucoencephalopathy in AIDS camouflaged with catatonia: A wolf in sheep's clothing

Catatonia

Catatonia is a neuropsychiatric disorder characterized by motor, affective and cognitive-behavioural signs, which lasts from hours to days. Intensive research over the past two decades has led to catatonia being recognized as an independent diagnosis in the International Classification of Diseases, 11th Revision (ICD-11) since 2022. Catatonia is found in 5-18% of inpatients on psychiatric units and 3.3% of inpatients on medical units. However, in an unknown number of patients, catatonia remains unrecognized and these patients are at risk of life-threatening complications. Hence, recognizing the symptoms of catatonia early is crucial to initiate appropriate treatment to achieve a favourable outcome. Benzodiazepines such as lorazepam and diazepam, electroconvulsive therapy, and N-methyl-D-aspartate antagonists such as amantadine and memantine, are the cornerstones of catatonia therapy. In addition, dopamine-modulating second-generation antipsychotics (for example, clozapine and aripiprazole) are effective in some patient populations. Early and appropriate treatment combined with new screening assessments has the potential to reduce the high morbidity and mortality associated with catatonia in psychiatric and non-psychiatric settings.

Electroconvulsive therapy (ECT) with ketamine induction for catatonia in an HIV positive patient

Introduction

The successful use of ECT as treatment for catatonia, in the context of HIV (human immunodeficiency virus) infection, has been described previously. Ketamine has been used as an anaesthetic induction agent for ECT, although not considered the induction agent of choice. There are also case reports suggesting that ketamine may be an alternative treatment specifically for catatonia.

Patient presentation

This case report describes the management of a female patient who presented with catatonia, evidenced by stupor, waxy flexibility, mutism, negativism, and stereotypy, as well as stage four HIV infection, with poor response to previous psychotherapeutic interventions.

Management and outcome

We describe the course of management of this patient with ECT, following poor initial clinical response to ECT with propofol induction, the subsequent use of ketamine as an anaesthetic induction agent for ECT, with associated improvement in seizure quality, and good overall clinical response to ECT demonstrated thereafter.

Conclusion and contributions

This case report suggests that ketamine may be a viable induction agent for ECT in this clinical setting.

Phenomenology and treatment of Catatonia: A descriptive study from north India

BACKGROUND

Studies on clinical features of catatonia in the Indian population are few in number.

AIM

To study the phenomenology, clinical profile and treatment response of subjects admitted to the psychiatry inpatient with catatonia.

MATERIALS AND METHODS

Detailed treatment records of all the inpatients were scanned for the period January 2004 to December 2008. Patients with catatonia (diagnosed as two symptoms as per the Bush Francis Catatonia Rating scale) were included.

RESULTS

During the study period, 1056 subjects were admitted in the inpatient unit, of which 51 (4.8% of the total admissions) had catatonic features and had been rated on the Bush Francis Catatonia Rating scale. The mean age of the sample was 30.02 years (SD=14.6; range 13-69), with an almost equal gender ratio. Most of the patients presenting with catatonia were diagnosed as having psychotic disorders (40; 74.8%), of which the most common diagnosis was schizophrenia (27; 52.9%) of the catatonic subtype (20; 39.2%). Three subjects with primary diagnosis of a psychotic disorder had comorbid depression. Other diagnoses included mood disorders (7; 13.72%) and organic brain syndromes (04; 7.9%). According to the Bush Francis Rating scale, the common signs and symptoms exhibited by the subjects were mutism (94.1%), followed by immobility/stupor (78.5%), staring (78.4%), negativism (74.5%), rigidity (63%) and posturing/catalepsy (61.8%). All the patients were initially treated with lorazepam. Electroconvulsive therapy was required in most cases (42; 82.35%).

CONCLUSION

The common symptoms of catatonia are mutism, immobility/stupor, staring, posturing, negativism and rigidity. The most common underlying psychiatric diagnosis was schizophrenia.

HIV and mental health: An overview of research from India

HIV/AIDS has gained prominence in India as a growing public health issue. There is a complex but significant interaction between mental health and HIV/AIDS. HIV affects mental health by its direct neurobiological action, the impact of having the illness, by its treatment including that for opportunistic infections and by its impact on the family. In addition, substance use and mental illness as vulnerability factors add to the complexity of assessment, differential diagnosis and management. This paper reviews literature published in India on the topic.