Psychosomatics 45:363-364, August 2004
© 2004 The Academy of Psychosomatic Medicine
Catatonia With Thrombotic Thrombocytopenic Purpura
Adeeb Yacoub, M.D.,
Izchak Kohen, M.D., and
Andrew Francis, M.D., Stony Brook, N.Y.
Key Words: schizophrenia • conventional neuroleptics • other neuropsychiatric disorders
TO THE EDITOR: We report a case of new-onset catatonia in a patient with a documented history of thrombotic thrombocytopenic purpura but no psychiatric history. This case raises the possibility of a correlation between catatonia and thrombotic thrombocytopenic purpura. The case also highlights the increased sensitivity in patients with thrombotic thrombocytopenic purpura to neuroleptic-induced catatonia.
Case Report
Ms. A, a 28-year-old woman with no psychiatric history and a diagnosis of thrombotic thrombocytopenic purpura on outpatient plasmapheresis, was admitted to the hospital with an infected subclavian port. She was febrile, with a temperature of 101.3°F. She was alert, oriented, and had spontaneous speech and movement at her admission to the hospital for intravenous antibiotics and replacement of the port.
On her first day of admission, she received meperidine intravenously after developing rigors and pain from the plasmapheresis treatment. She became lethargic and received naloxone to reverse the effects of the meperidine. She became more alert but also agitated. She received 2.5 mg of haloperidol from an intravenous push and subsequently became confused and lethargic. Her vital signs included a tachycardic pulse and a labile blood pressure. She was obtunded and nonverbal at this point and was transferred to the medical intensive care unit.
In intensive care, she was described as responding only to her name and was mute except for moaning and grimacing. She had purposeless arm movements with negativism and resistance of movement. For example, she would move her head away when the nurse tried to feed her. Ms. A was not able to follow commands at that time. A computerized tomography scan was negative for bleeding or an infarct.
A psychiatry consult was requested on the second day. The psychiatrist found her to have autonomic instability of heart rate and blood pressure, grimacing, mild catalepsy, withdrawal, and mutism. She had at least mild findings on five of the 14 items on the Bush-Francis Catatonia Rating Scale.1 Ms. A was given lorazepam, 1 mg, with an intravenous push, and within 5 to 10 minutes, she had mild improvement in her symptoms, with more spontaneous, purposeful movements.2
Ms. A was given lorazepam, 1 mg b.i.d., with an intravenous push and began to improve quickly. On the third day, the nurses documented that she was more spontaneous and less withdrawn. She opened her eyes when her name was called and did not turn her head away when cleaning swabs were placed at her mouth. Her lorazepam was increased to 3 mg/day on the fourth day, and she began to speak coherently. She recognized her mother and photos of her husband. She could not recall the events of the previous days. Her lorazepam was increased to 4 mg/day on the fifth day, and she continued to improve, with spontaneous oral intake and no evidence of catatonia. She was transferred to a regular medical floor and was discharged from the hospital on the seventh day, taking 4 mg/day of lorazepam.
Discussion
The classic description of thrombotic thrombocytopenic purpura includes a pentad of diagnostic criteria: thrombocytopenia, hemolytic anemia, renal insufficiency, fever, and neurological symptoms.3 Neurological impairment is seen in more than 80% of patients with thrombotic thrombocytopenic purpura and includes headaches, paresis, visual disturbances, seizures, cognitive changes, aphasia, and coma.4
We found one prior documented case report of catatonia in the presence of thrombotic thrombocytopenic purpura in the literature. However, that patient had a prior psychiatric diagnosis of "catatonic schizophrenia with atypical features."5 As seen in this case report, catatonia can be found in many medical conditions, even in the absence of a psychiatric history or a current psychiatric illness.6
This case report raises concerns about the safety of conventional neuroleptics in agitated patients with thrombotic thrombocytopenic purpura. There are case reports of high-potency typical neuroleptics being associated with catatonic reactions.7 Thrombotic thrombocytopenic purpura may make patients more sensitive to high-potency typical neuroleptic-induced catatonia. Recently, intramuscular atypical neuroleptics, such as ziprasidone, have been proven to be equally effective in the treatment of acute agitation.8 Perhaps atypical injectable neuroleptics would be safer in the treatment of agitation in patients with thrombotic thrombocytopenic purpura. More research and more information are needed on this subject.
REFERENCES
- Bush G, Fink M, Petrides G, Dowling F, Francis A: Catatonia I: rating scale and standardized examination. Acta Psychiatrica Scandinavica 1996; 93:129–136[Medline]
- Fricchione G, Cassem N, Hooberman D, Hobson D: Intravenous lorazepam in neuroleptic-induced catatonia. J Clin Psychopharmacol 1983; 3:338–342[Medline]
- Amorosi EL, Ultmann JE: Thrombotic thrombocytopenic purpura: report of 16 cases and review of the literature. Medicine 1966; 45:139–159
- Moschcowitz E: An acute febrile pleiochromic anemia with hyaline thrombosis of the terminal arterioles and capillaries: an undescribed disease. Arch Intern Med 1975; 35:89–93
- Read SL: Catatonia in thrombotic thrombocytopenic purpura: case report. J Clin Psychiatry 1983; 44:343–344[Medline]
- Carroll BT, Anfinson TJ, Kennedy JC, Yendrek R, Boutros M, Bilon A: Catatonic disorder due to general medical conditions. J Neuropsychiatry Clin Neurosci 1994; 6:122–133[Abstract/Free Full Text]
- Gelenberg AJ, Mandel MR: Catatonic reactions to high-potency neuroleptic drugs. Arch Gen Psychiatry 1977; 34:947–950[Abstract]
- Klotz SG, Preval H, Southard R, Francis A: Injectable ziprasidone in the psychiatric emergency service, in 2003 Annual Meeting New Research Program and Abstracts. Arlington, Va, American Psychiatric Association, 2003
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