Malignant catatonia in a patient with bipolar disorder, B12 deficiency, and neuroleptic malignant syndrome: one cause or three?
A Case is presented of a 23-year-old woman with progressive onset of paranoid psychosis and catatonia, who was ultimately found to have both vitamin B12 deficiency and a family history of bipolar disorder. The patient was initially diagnosed with schizophrenia and treated with the antipsychotic medication ziprasidone. Her condition rapidly worsened to a state consistent with either neuroleptic malignant syndrome or malignant catatonia. Work-up then revealed vitamin B12 deficiency and a family history of bipolar disorder. Her symptoms improved rapidly but partially with benzodiazepines and electrocon-vulsive therapy, and completely with addition of valproic acid, vitamin B12 replacement, and re-introduction of antipsychotic medication in the form of olanzapine. The authors discuss the differential diagnosis of catatonia as reflecting a high likelihood of underlying mood disorder; the evaluation and management of malignant catatonia and malignant neuroleptic syndrome; and the role of vitamin B12 deficiency in precipitating psychotic symptoms. The case also illustrates the problems of diagnosing and managing a multifactorial disorder with psychiatric, general medical, and perhaps iatrogenic components.
Lewis
A Lee
AL
Medical University of South Carolina, Charleston, USA.
Pelic
Christopher
C
Kahn
David A
DA
D001714:Bipolar Disorder / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D002389:Catatonia / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D009459:Neuroleptic Malignant Syndrome / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D012563:Schizophrenia, Paranoid / Q000175:diagnosis; D014806:Vitamin B 12 Deficiency / Q000150:complications* / Q000628:therapy; D055815:Young Adult