MALIGNANT CATATONIA IN MEDICAL WARDS: A BROAD DIFFERENTIAL DIAGNOSIS

Introduction Catatonia is an uncommon and heterogeneous psychomotor syndrome. It can be not only the manifestation of a psychiatric disorder but also a wide range of medical conditions. The malignant catatonia is a subtype of catatonia which includes dysautonomic signs such as hyperthermia or hemodynamic instability, and because most of the affected patients are taking antipsychotics or antidepressants previously, it can be confounded with medical conditions such as neuroleptic or serotonin syndrome. Objectives To present a case of malignant catatonia admitted in a medical ward Methods The present study is a case report of a patient admitted with initial diagnosis of serotonin syndrome in a medical ward of our hospital and referred to the consultation and liaison psychiatry (CLP) unit. We also searched previously case reports, series and systematic reviews about catatonia secondary to medical conditions and hyperthermia catatonia. Results Ms. TN is a 71-year-old woman, with prior history of major depressive disorder. One month ago she was admitted in a psychiatric ward of another hospital for a depressive episode with psychotics features, and was treated with escitalopram 10mg/day, vortioxetine 10mg/day, mirtazapine 15mg/day, trazodone 50mg/day, quetiapine 700mg/day and haloperidol 5mg/day. She had a worsening of depressive symptoms with suicidal thoughts, negativism and psychomotor retardation, and subsequently hyperthermia, rigidity, mydriasis, tachicardia and increased bowel sound. She was tranfered to our medical ward, and diagnosed of serotonin syndrome. She was stopped all the psychiatric drugs and was treated with dantrolene and support measures. After 10 days without antidepressants or antipsychotics she maintened the same symptomatology and was referred to our CLP unit. The psychopathological evaluation showed stupor, mutism, waxy flexibility and negativism, and she responded to a challenge test with intravenous clonazepam 0,5mg. She was diagnosed of malignant catatonia and was started oral clonazepam 2mg/day. Although there was a partial response, she did not tolerate higher doses because of sedation and finally was treated with electroconvulsive therapy (ECT). She dad a remission of catatonic symptoms after only two sessions of ECT. Conclusions Malignant catatonia can be confounded with other medical conditions such as serotonin or neuroleptic syndromes. All of them can have catatonic signs, and it is important to recognize them (a challenge test with a benzodiacepine can be helpful). The key to distingish malignant catatonia from them is that some of the catatonic signs (negativism and psychomotor retardation) happened before the dysautonomic signs. Also, it is uncommon that a serotonin syndrome persisted more than 3-5 days after the suspension of antidepressants. Consultation and liaison psychiatrists can help for the differential diagnosis and management of patients with suspected catatonia in medical wards. Disclosure of Interest None Declared

Introduction: Hyperthyroidism due to Graves-Basedow disease is a common cause of neuropsychiatric manifestations, such as anxiety, psychomotor restlessness, mood disturbances, insomnia and psychosis.Hashimoto's encephalopathy rarely occurs in so-called autoimmune thyroiditis, which can present with hyperthyroidism and neuropsychiatric symptoms similar to Graves' disease.We add that the mystical-religious beliefs, present in all human cultures, and decisive in the case at hand, make us propose an evolutionary origin of them.Objectives: Clinical case description Methods: A clinical case based on medical reports is described Results: We present the case of a 72-year-old woman, a member of the Seventh-day Adventist Church, well adapted to the Community.Known history of elevated antithyroid antibodies since 2019, brought to the emergency room involuntarily due to a mysticalreligious delusional condition associated with behavioral disturbance.On examination, cachectic appearance, distal tremor, emotional exaltation and megalomanic speech were highlighted.Laboratory tests revealed primary hyperthyroidism with elevated antibodies.During admission, the differential diagnosis between Graves-Basedow disease and Hashimoto's encephalopathy was considered.Thyroid scintigraphy oriented the diagnosis to Graves-Basedow disease, not requiring lumbar puncture or corticosteroid treatment.Treatment was based on high-dose antithyroid and antipsychotic drugs, with clinical and analytical remission at 3 weeks.The patient was referred to a Social Health Center for functional recovery.The family refers to a similar episode in 2014, of less intensity and self-limited, which is proposed to be a hashitoxicosis.

Conclusions: Differential diagnosis between Graves-Basedow and
Hashimoto disease is essential as they differ in treatment and prognosis.The continuity that the delusion presents with the previous beliefs of the patient, differing mainly in the affectivebehavioral implication, makes us consider a predisposition to psychosis in our patient.Religiosity can be adaptive in certain environments, since mystical beliefs have existed throughout the history of the human species and seem to be part of our nature.Introduction: Catatonia is an uncommon and heterogeneous psychomotor syndrome.It can be not only the manifestation of a psychiatric disorder but also a wide range of medical conditions.The malignant catatonia is a subtype of catatonia which includes dysautonomic signs such as hyperthermia or hemodynamic instability, and because most of the affected patients are taking antipsychotics or antidepressants previously, it can be confounded with medical conditions such as neuroleptic or serotonin syndrome.

Disclosure of
Objectives: To present a case of malignant catatonia admitted in a medical ward Methods: The present study is a case report of a patient admitted with initial diagnosis of serotonin syndrome in a medical ward of our hospital and referred to the consultation and liaison psychiatry (CLP) unit.We also searched previously case reports, series and systematic reviews about catatonia secondary to medical conditions and hyperthermia catatonia.Results: Ms. TN is a 71-year-old woman, with prior history of major depressive disorder.One month ago she was admitted in a psychiatric ward of another hospital for a depressive episode with psychotics features, and was treated with escitalopram 10mg/day, vortioxetine 10mg/day, mirtazapine 15mg/day, trazodone 50mg/ day, quetiapine 700mg/day and haloperidol 5mg/day.She had a worsening of depressive symptoms with suicidal thoughts, negativism and psychomotor retardation, and subsequently hyperthermia, rigidity, mydriasis, tachicardia and increased bowel sound.She was tranfered to our medical ward, and diagnosed of serotonin syndrome.She was stopped all the psychiatric drugs and was treated with dantrolene and support measures.After 10 days without antidepressants or antipsychotics she maintened the same symptomatology and was referred to our CLP unit.The psychopathological evaluation showed stupor, mutism, waxy flexibility and negativism, and she responded to a challenge test with intravenous clonazepam 0,5mg.She was diagnosed of malignant catatonia and was started oral clonazepam 2mg/day.Although there was a partial response, she did not tolerate higher doses because of sedation and finally was treated with electroconvulsive therapy (ECT).She dad a remission of catatonic symptoms after only two sessions of ECT.Conclusions: Malignant catatonia can be confounded with other medical conditions such as serotonin or neuroleptic syndromes.All of them can have catatonic signs, and it is important to recognize them (a challenge test with a benzodiacepine can be helpful).The key to distingish malignant catatonia from them is that some of the catatonic signs (negativism and psychomotor retardation) happened before the dysautonomic signs.Also, it is uncommon that a serotonin syndrome persisted more than 3-5 days after the suspension of antidepressants.Consultation and liaison psychiatrists can help for the differential diagnosis and management of patients with suspected catatonia in medical wards.

EPV0277
A Case of Severe Somatized Depression in a Young Adult: Diagnostic Challenges Introduction: Depressive disorders in adolescence and young adulthood have always been and remain an urgent problem due to their fairly high prevalence among the population, serious difficulties in diagnosis and untimely treatment.Timely diagnosis and adequate treatment can have a powerful impact on the future life of a person in a positive context.This process requires both standardized mechanisms, and an individual detailed study of each case, as the future of the individual depends on it.Objectives: A young adult M., 20 years old, a university student, from a socially prosperous family, approached us.Main complaints: headaches that have been going on for almost 4 years.Pains did not depend on loads, both physical and mental, were of various characteristic and different localization.Nonsteroidal anti-inflammatory drugs, as well as anti-migraine drugs, have little effect on the pathological experiences.Methods: Our main method of examination was clinical interview.In the complex assessment detailed neurological and ophtalmological examination included.Results: The parents referred patient for a medical examination about a year ago, because they noticed persistent mydriasis in him.During the year, the patient underwent a detailed examination (consultations of a therapist, endocrinologist, neurologist, ophthalmologist, MRI, EEG, dopplerography).Doctors expressed various assumptions about the diagnosis, because all the studies did not reveal any pathology that could explain the indicated complaints and mydriasis.During the initial interview, a high level of intelligence and knowledge was revealed, as well as a sufficient ability to learn.Examining the emotional-volitional sphere, a slight level of emotional instability, mild irritability, anhedonia and a slight degree of hypobulia (which can be explained by long-lasting and persistent pathological somatic experiences in the form of headaches) were found.Incomplete Protopopov's triad was revealed.The patient was referred for repeated neurological and ophthalmological examination.Specialists with a high qualification level discovered the A. Athanassio symptom in him.He was diagnosed with recurrent depressive disorder, a current episode of severe depression with somatic symptoms, and appropriate treatment was prescribed.

Conclusions:
1. Depressive disorders in adolescence and young adulthood require special attention from specialists of all medical specialties.2. The need for a detailed medical examination and modern neuroimaging methods is beyond doubt.3. Psychiatric examination cannot be limited to assessment of mental status only, and assessment of Protopopov's triad should be part of psychiatric examination.4. Neurological and ophthalmological examination must necessarily include an assessment of neuro-ophthalmological symptoms.5. Individual selection of treatment should be carried out by a psychiatrist.
Sorry to say, Professor Mykola Pityk died 27.12.2020 Disclosure of Interest: None Declared

EPV0278
Psychosis in a Patient with Muscular Dystrophy : Case Report and Literature Review Introduction: Knowledge about muscular dystrophies and in particular X-linked inherited disorders such as Duchenne and Becker Muscular Dystrophy has been gradually acquired as more research studies have been conducted to better understand the pathogenesis, management and prognosis of these conditions.However, little is known about a probable correlation between muscular dystrophies and neuropsychiatric disorders.We present the case of a 41-year-old male with history of a mild rare form of muscular dystrophy and elevated CPK level, who presents with psychotic symptoms that resolve with proper management of the underlying medical condition.
Objectives: The purpose of this case report is to emphasize the importance of being mindful when diagnosing patients with a psychiatric illness as psychotic symptoms could also result from underlying rare muscular dystrophies.Methods: A comprehensive review of literature using databases, such as PubMed and Google Scholar was conducted to gain a better understanding of this specific disorder and to rule out conditions that present in a similar way.Keywords used were Muscular Dystrophy, Elevated CPK, Psychosis, Becker, Duchenne.
Results: Data shows that patients with these muscular dystrophies have mutations that affect Dp71 expression.Moreover, Dp71 is expressed in postsynaptic membranes in the glutaminergic pathway whose alteration might contribute to neuropsychiatric disorders.As there is growing body of evidence of rhabdomyolysis encountered in patients treated with antipsychotics, there is less data available about a possible causal relationship between rhabdomyolysis and subsequently elevated CPK inducing psychosis.
Conclusions: Further studies could be helpful to explore a possible correlation between an elevated CPK level and psychotic symptoms as demonstrated by this case report.A thorough history taking, psychiatric and medical evaluations would prevent misdiagnosis of psychiatric disorders and would lead to proper management of these rare cases.
Disclosure of Interest: None Declared