S009: POSTOPERATIVE CATATONIA IN A PATIENT WITH UNKNOWN SEVERE MAJOR DEPRESSIVE DISORDER
Tomas Delgado Jr., MD, MPH1; Giselle De La Rua, BS2; Adryan Perez, MD1; Christian Diez, MD, MBA1
1Jackson Memorial Hospital/University of Miami; 2University of Miami Miller School of Medicine
Background: Catatonia is described as a neuropsychiatric syndrome characterized by onset of abnormal movements and behaviors often seen in the setting of comorbid psychiatric disorders. While the presentation of catatonia often varies, characteristic symptoms include stupor, waxy flexibility, catalepsy, mutism, posturing, negativism, stereotyping, echopraxia and echolalia. Catatonia is a rare, although well documented, postoperative complication most often seen following solid organ transplant, however it has been documented following a number of other surgical procedures.
Case: The patient is a 22 year old previously healthy man who presented for incision and drainage of chronic subcutaneous bilateral neck abscesses. After standard induction and emergence, there were no perioperative complications. In the post-operative recovery unit, we were notified that the patient had muscle weakness. Evaluation revealed significant motor weakness of the bilateral upper and lower extremities, reduced sensation to light touch, no reaction to painful stimuli, weakening voice, and blunted affect.
A stroke alert was activated with prompt evaluation by neurology and CT/CTA/MRI brain/neck/spine showing normal findings without pathology. The patient became unresponsive to auditory and tactile stimuli, exhibiting flaccid paralysis without airway compromise. Arterial blood gas obtained within normal limits. He was noted to have spontaneous movement of toes, head, and flickering eyes. He received lorazepam and levetiracetam. The patient was transferred to the ICU for hemodynamic monitoring.
Approximately 20 minutes after arrival, he was noted to be somnolent, following commands, and speaking. Repeat MRI brain/neck/spine and continuous EEG did not show any abnormalities. Psychiatric evaluation revealed severe major depressive disorder with a history of depression, anxiety, and multiple suicide attempts. His neurologic status returned to baseline after 3 days. Given the absence of neurologic pathology to explain the patient’s presentation, we propose it was consistent with major depressive disorder with catatonia, although conversion disorder and delayed anesthesia emergence were also considered.
Discussion: In the setting of postoperative weakness, anesthetic-related complications such as residual neuromuscular blockade must first be ruled out. In this case, the patient was reversed with sugammadex with full TOF on neuromuscular monitoring and spontaneous movement of extremities upon extubation. While considering other organic processes, his negative workup pointed towards an underlying psychogenic etiology. Although this patient lacked easily recognizable symptoms such as waxy flexibility, echophenomena, or catalepsy; his hypokinesis (immobility), weakening voice (mutism), and decreasing alertness (stupor) are consistent with catatonia per DSM-5 criteria. His history of severe MDD further supports this diagnosis given the established association between catatonia and mood disorders.
Conclusion: This case exemplifies the importance of a broad differential when considering etiologies of postoperative weakness. Patients who present with continued or fluctuating weakness despite appropriate reversal of paralysis, negative imaging, and normal blood work should be quickly assessed for additional symptoms and unknown psychiatric history. It can be beneficial to involve neurology and psychiatry early in the patient course to assist with diagnosis. Postoperative catatonia, although rare, is not an improbable diagnosis in the setting of unexplained neurological symptoms and should be considered in atypical presentations.