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Catatonic syndrome associated with enteric fever
Catatonic Syndrome Associated with Enteric Fever A Case Report
Generally considered to be a subtype of schizophrenia, catatonia is known to occur in other psychiatric disorders and a variety of neurologic and medical illness and should be regarded as a syndrome with diverse underlying causes [l]. In this report, we present a case of catatonic syndrome associated with enteric fever.
An M-year-old girl presented to the medical outpatient clinic on July 29, 1987 with a history of fever of 15 days’ and altered sensorium of 4 days’ duration. Subsequent to the onset of fever, the patient had sought treatment from a general practitioner and became afebrile after 1 week. Four days later, however, she became mute, refused to eat and was incontinent of urine and feces. On examination, the patient was mildly febrile (38” C). Various system examinations, including central nervous system, did not reveal any abnormality except for bilaterally symmetrical brisk deep tendon reflexes. The diagnosis at the time of admission was enteric fever, which was substantiated by a positive blood culture and a widal test. A lumbar puncture done at this stage was normal. Other blood parameters and chest x-rays did not reveal any abnormality. The patient was started on parenteral chloramphenicol and steroids; and she became afebrile 3 days later. Nevertheless, as she continued to be mute and was incontinent of urine and feces, a psychiatric opinion was sought. On examination, the patient was mute and would actively resist the physicians’ and nurses’ commands. Her face was expressionless. She would allow the examiner to put her bodily parts into uncomfortable positions and would maintain such positions for a long time, suggesting catalepsy.
General Hospital Psychiatry 11, 71-72, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Prior to the onset of this illness, the patient was in good health and was a well-adjusted person. She had never abused any drugs or alcohol in the past. There was no family history of any psychiatric illness. After the psychiatry consultation, the patient was administered trifluoperazine, 15 mg/day. Two days later, she had two generalized seizures and antipsychotics were withdrawn. The patient had never had seizures in the past, nor were any family members suffering from epilepsy. She was administered diphenylhydantoin, 200 mglday and trifluoperazine was gradually reintroduced. A repeat cerebrospinal fluid examination conducted at this stage was normal. As the patient’s psychiatric status remained the same over the next 2 weeks regardless of an adequate dose of trifluoperazine, she was transferred to the psychiatry ward for electroconvulsive therapy (ECT). She received ten modified, bilateral ECT treatments every alternate day, and at the end of 3 weeks she had recovered to her premorbid level of functioning.
Varieties of neuropsychiatric manifestations associated with enteric fever have been described in the literature; these manifestations include confusional state, muttering delirium [2], schizophreniform psychosis [3], paranoia, melancholia, and hysteria [4]. Our case was distinct from these reports in that the patient had manifested classical signs of catatonic syndrome that appeared after the toxic phase of enteric fever had been controlled, and is in agreement with an earlier report [5]. The relationship of psychiatric symptoms to enteric fever remains, however, unclear. Hafeiz [6] has suggested that the typhoid infection and, to a lesser extent, a susceptible personality seem to be im-
71 ISSN 0163-8343/89/$3.50
K. Srinivasan et al.
portant etiologic factors in the genesis of psychiatric symptoms. Another salient feature was the excellent therapeutic response to modified ECT therapy.
K. Srinivasan, M.D. K. S. Chandra Mouli, M.D. Eugene Thomas, M.B.B.S. Moire S. Jacob, F.R.C.P. S. D. Tarey, M.D. St. John’s Medical College Hospital Karanataka, India
72
References syndrome. Lancet 1. Gelenberg AJ: The catatonic 1:1339-1341, 1976 2. Varghese A: The “Typhoid State” revisted. Am J Med 79:370-372, 1985 3. Osuntokun BO, Bademosi 0, Ogunremi K, Wright SG: Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol27:7-13, 1972 4. Gadeholt H, Madsen ST: Course, complications and mortality in typhoid fever as compared with paratyphoid B: A survey of 2647 cases. Acta Med Stand, 174:753-760, 1963 Breakey WR, Kala AK: Typhoid catatonia responsive 5. to ECT. Br Med J 2:357-359, 1977 6. Hafeiz BH: Psychiatric manifestions of enteric fever. Acta Psychiatr Stand 75:69-73, 1987
Generally considered to be a subtype of schizophrenia, catatonia is known to occur in other psychiatric disorders and a variety of neurologic and medical illness and should be regarded as a syndrome with diverse underlying causes [l]. In this report, we present a case of catatonic syndrome associated with enteric fever.
An M-year-old girl presented to the medical outpatient clinic on July 29, 1987 with a history of fever of 15 days’ and altered sensorium of 4 days’ duration. Subsequent to the onset of fever, the patient had sought treatment from a general practitioner and became afebrile after 1 week. Four days later, however, she became mute, refused to eat and was incontinent of urine and feces. On examination, the patient was mildly febrile (38” C). Various system examinations, including central nervous system, did not reveal any abnormality except for bilaterally symmetrical brisk deep tendon reflexes. The diagnosis at the time of admission was enteric fever, which was substantiated by a positive blood culture and a widal test. A lumbar puncture done at this stage was normal. Other blood parameters and chest x-rays did not reveal any abnormality. The patient was started on parenteral chloramphenicol and steroids; and she became afebrile 3 days later. Nevertheless, as she continued to be mute and was incontinent of urine and feces, a psychiatric opinion was sought. On examination, the patient was mute and would actively resist the physicians’ and nurses’ commands. Her face was expressionless. She would allow the examiner to put her bodily parts into uncomfortable positions and would maintain such positions for a long time, suggesting catalepsy.
General Hospital Psychiatry 11, 71-72, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Prior to the onset of this illness, the patient was in good health and was a well-adjusted person. She had never abused any drugs or alcohol in the past. There was no family history of any psychiatric illness. After the psychiatry consultation, the patient was administered trifluoperazine, 15 mg/day. Two days later, she had two generalized seizures and antipsychotics were withdrawn. The patient had never had seizures in the past, nor were any family members suffering from epilepsy. She was administered diphenylhydantoin, 200 mglday and trifluoperazine was gradually reintroduced. A repeat cerebrospinal fluid examination conducted at this stage was normal. As the patient’s psychiatric status remained the same over the next 2 weeks regardless of an adequate dose of trifluoperazine, she was transferred to the psychiatry ward for electroconvulsive therapy (ECT). She received ten modified, bilateral ECT treatments every alternate day, and at the end of 3 weeks she had recovered to her premorbid level of functioning.
Varieties of neuropsychiatric manifestations associated with enteric fever have been described in the literature; these manifestations include confusional state, muttering delirium [2], schizophreniform psychosis [3], paranoia, melancholia, and hysteria [4]. Our case was distinct from these reports in that the patient had manifested classical signs of catatonic syndrome that appeared after the toxic phase of enteric fever had been controlled, and is in agreement with an earlier report [5]. The relationship of psychiatric symptoms to enteric fever remains, however, unclear. Hafeiz [6] has suggested that the typhoid infection and, to a lesser extent, a susceptible personality seem to be im-
71 ISSN 0163-8343/89/$3.50
K. Srinivasan et al.
portant etiologic factors in the genesis of psychiatric symptoms. Another salient feature was the excellent therapeutic response to modified ECT therapy.
K. Srinivasan, M.D. K. S. Chandra Mouli, M.D. Eugene Thomas, M.B.B.S. Moire S. Jacob, F.R.C.P. S. D. Tarey, M.D. St. John’s Medical College Hospital Karanataka, India
72
References syndrome. Lancet 1. Gelenberg AJ: The catatonic 1:1339-1341, 1976 2. Varghese A: The “Typhoid State” revisted. Am J Med 79:370-372, 1985 3. Osuntokun BO, Bademosi 0, Ogunremi K, Wright SG: Neuropsychiatric manifestations of typhoid fever in 959 patients. Arch Neurol27:7-13, 1972 4. Gadeholt H, Madsen ST: Course, complications and mortality in typhoid fever as compared with paratyphoid B: A survey of 2647 cases. Acta Med Stand, 174:753-760, 1963 Breakey WR, Kala AK: Typhoid catatonia responsive 5. to ECT. Br Med J 2:357-359, 1977 6. Hafeiz BH: Psychiatric manifestions of enteric fever. Acta Psychiatr Stand 75:69-73, 1987