Systemic Lupus Erythematous Presenting as Catatonia and its Response to Electroconvulie Therapy

The Cotard Delusion in a Patient With Neuropsychiatric Systemic Lupus Erythematosus: The Challenges of Autoimmune Psychosis

The clinical features of neuropsychiatric systemic lupus erythematosus (NPSLE) are heterogeneous. Furthermore, therapeutic decision-making for NPSLE depends on the recognition of clinical syndromes that have not been sufficiently studied. This report describes the case of a 36-year-old woman with NPSLE who exhibited severe cognitive dysfunction and affective psychosis with persistent nihilistic delusions such as those described in the Cotard delusion. The patient insisted for several months that she was already dead. CSF analysis showed elevated levels of anti-ribosomal P antibodies and a positive determination of oligoclonal bands. Additionally, 18F -FDG PET/CT imaging revealed severe bilateral frontal hypermetabolism suggestive of brain inflammation and occipital hypometabolism. Results from the Systematic Lupus Erythematosus Disease Activity Index 2000 and the Systemic Lupus Erythematosus Disease Activity Score were consistent with an active state of the immunological disease. We then determined by an algorithm that this neuropsychiatric event could be attributed to the activity of the underlying immunological disease. Despite immunosuppressive and symptomatic treatment, only a partial improvement in cognition was achieved. The psychopathological features of the Cotard delusion remained unchanged 4 months after onset. However, we observed rapid remission of affective psychosis and significant improvement in cognition following electroconvulsive therapy. Subsequent follow-up examinations showed a sustained remission. This case describes a protracted form of the Cotard delusion, the diagnostic challenges that arise in the context of SLE, and treatment dilemmas that necessitate collaboration between neurology, psychiatry, and rheumatology.

Catatonia in systemic lupus erythematosus: case based review

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).

A Case of Prolonged Catatonia Caused by Sjögren's Syndrome

Sjögren's syndrome (SS) is a chronic autoimmune disorder, often associated with some neuropsychiatric symptoms as well as systemic lupus erythematosus. Although catatonia is frequently reported in patients with systemic lupus erythematosus, it has been rarely reported in patients with SS. Herein, we present a case of SS with catatonia effectively and safely treated with modified electroconvulsive therapy (ECT). A 58-year-old woman showed prolonged catatonia and depressive mood along with pathologically dried eye and mouth. Based on physical findings and blood tests, she was diagnosed with SS. Because of the presence of pressure sores, we were unable to perform lumbar puncture for the diagnosis of abacterial encephalitis. Alternatively, single-photon emission computed tomography of her brain revealed multifocal hypoperfused areas in the parietotemporal region. Consequently, we performed ECT for the treatment of catatonia comorbid with SS. Following 20 sessions of ECT, the catatonia was improved without obvious adverse effects. One week after the last ECT, elevated levels of interleukin-6 were identified in the cerebral fluid. After receiving steroid pulse therapy, she has not experienced catatonia for more than 5 years. SS can cause catatonia, and ECT is a safe and effective option for the treatment of catatonia with SS.

Anesthesia Management of Special Patient Populations Undergoing Electroconvulsive Therapy: A Review

Electroconvulsive therapy (ECT) is the safe application of electricity to the scalp of a patient, using brief-pulse stimulation techniques under general anesthesia and muscle paralysis, inducing a series of generalized epileptic seizures. Principal indications for ECT are major depression (unipolar or bipolar) with a lack of response to medications, intolerance to medications due to side effects or coexisting conditions, the need for a rapid response because of other conditions such as catatonia, psychosis, suicidality, or clinically significant dehydration or malnutrition, mania, and schizophreniform disorder or schizoaffective disorder, and, medical disorders such as Parkinson's disease, neuroleptic malignant syndrome, and chronic pain. Anesthesia management of special patient populations undergoing ECT has been described in textbooks and guidelines, but some descriptions may be antiquated. Therefore, this review describes recent knowledge on anesthesia management of patients who require ECT, such as those with neurologic disorders, cardiovascular disorders, pregnancy, and other concurrent medical illness. Based on the findings of a recent paper, ECT may be safer than is widely reported. According to the American Psychiatric Association, ECT has no absolute contraindications; however, some conditions pose a relatively high risk, and there are many other kinds of complications associated with ECT that can lead to death. Understanding such complications and their management strategies can avoid unnecessary discontinuation of treatment due to manageable complications of ECT and, furthermore, ECT clinicians must also consider the risk-benefit ratio when treating high-risk patients.

Catatonia Associated With Systemic Lupus Erythematosus (SLE): A Report of Two Cases and a Review of the Literature

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.