A 35-year-old Hindu vegetarian male was brought to the hospital with complaints of headache, fatigue, decreased interaction, and mood swings for 1 week. After a week he could not stand from bed in the morning and developed stiffness in whole body. His speech was slurred and incomprehensible. Patient never suffered from any psychiatric illness in the past and there was no history of substance use. He never underwent major surgical procedure or received any transplants or transfusion. Patient’s elder brother also suffered from an unknown medical disorder and died within 6 months of onset of illness.
On examination, the patient had mutism (Bush Francis Catatonia Rating Scale [BSFRS] score= 3), immobility (BSFRS score=3), rigidity (BSFRS score=3) in all limbs, waxy flexibility (BSFRS score=3) and positive grasp reflex (BSFRS score=3). He also had frequent brief myoclonic jerks. Neurological examination did not reveal any significant abnormality except hyperreflexia. Sensory examination could be done as patient was not cooperative but patient responded to painful stimuli. Bush Francis catatonia rating scale score was 19, suggestive of severe catatonia. Patient scored mainly on stupor, rigidity, waxy flexibility and grasp reflex. Vitals were stable and investigations including hemogram, platelet count, peripheral blood smear, serum glucose, ammonia, liver, renal, thyroid function tests, vitamin B12 level, serum venereal disease research laboratory (VDRL), electrolytes and other metabolic parameters were within normal limits. Serological tests for vasculitis were within normal limits. X- Ray chest, CT scan (plain and contrast) and CSF analysis did not reveal any significant abnormality. Scalp electroencephalography (EEG) showed diffuse slowing of background activity to delta range. Magnetic Resonance Imaging (MRI) of brain (Figure 1) revealed high signal intensity on T2 WI and fluid attenuated inversion recovery (FLAIR) in caudate nucleus, thalamus bilaterally (hockey stick sign), posterior cingulate and parietal lobe. Diffusion weighted images (Figure 2) showed bilateral symmetric hyperintense signals in the caudate, frontal, parietal and occipital region.
Figure 1.MRI Showing High Signal Intensity and Fluid Attenuated Inversion Recovery
Figure 2.Diffusion-Weighted Images Showing Symmetric Bilateral Hyperintense Signals in the Caudate, Frontal, Parietal, and Occipital Regions
He was admitted under specialized inpatient Neurological care with regular psychiatric consultations. The family refused ECT as a treatment modality and response to intravenous lorazepam was unsatisfactory.
The patient deteriorated rapidly in following months. He developed disorientation and became vegetative. His oral intake was poor and he gradually became more and more vegetative. With passing time he became dependent on supportive measures. Patient in terminal days developed bronchopneumonia and nearly 3 months after onset of the symptoms he expired.