Olanzapine and Lorazepam Used in the Symptomatic Management of Excited Catatonia Secondary to Anti-N-Methyl-D-Aspartate Receptor Encephalitis

Abstract

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis has become one of the more wellknown autoimmune diseases affecting the brain and it is characterized by a multitude of progressive neuropsychiatric symptoms. The following case describes the clinical course of an 18-year-old female with excited type catatonia secondary to anti-NMDA receptor encephalitis. The patient had been brought to the ED by her parents in an acutely psychotic state characterized by profound disorganization and vivid visual hallucinations. She was admitted to psychiatry and her hospital course was significant for both retarded and excited type catatonia, autonomic instability, and sensitivity to multiple neuroleptics. Given the atypicality of her symptoms and a family history of autoimmune disease, workup for autoimmune encephalitis was performed. MRI of the pelvis showed an indeterminate ovarian mass and laboratory studies were generally unremarkable. The catatonic symptoms resolved over the course of three weeks, eventually responding to a combination of lorazepam and olanzapine. Following discharge, a cerebrospinal fluid (CSF) panel resulted with positive titers for anti-NMDA receptor antibodies. This case illustrates the need to consider autoimmune encephalitis in cases of catatonia. It also presents a case in which symptoms of anti-NMDA receptor encephalitis potentially remitted without immunotherapy or mass resection.

Are benzodiazepines effective in treating catatonia?

“…This review highlights the paucity of RCTs on the use of benzodiazepines in catatonia, but this does not necessarily equate to a lack of an evidence base (Box 6). With case series (Petrides 1997;Mekala 2020;Neerukonda 2020) and observational studies (Raveendranathan 2012) demonstrating their efficacy, the use of placebo-controlled trials for an acute, life-threatening state could arguably be both dangerous and unethical. Although RCTs are held to be high-quality evidence (Fig.…”

“…The subtype of malignant catatonia is characterised by pyrexia, behavioural agitation, delirium and autonomic instability, alongside the motor symptoms typical of the disorder. This is a life-threatening condition where early diagnosis and treatment are crucial (Park 2017). Patients with catatonia are also at an increased risk of malnutrition, dehydration, pneumonia and venous thromboembolism (Regestein 1977; Penland 2006).…”