A 22-year-old woman presented with a 9-day history of intermittent fever and abnormal behavior. On the second day of her febrile illness, she developed fluctuating abnormal behavior characterized by apathy, nihilistic delusions, repetitive movements, and rapidly progressive rigidity of the whole body. She had no seizures. On admission, she was febrile (100°f), mute, and was avoiding eye contact. Saliva was pooled in the oral cavity and was drooling. There was axial and appendicular rigidity, fluctuating intermittently. There was intermittent prolonged posturing of limbs and opening of mouth. A differential diagnosis of viral encephalitis, acute psychosis, depressive stupor, and neuroleptic malignant syndrome (NMS) was entertained. She satisfied the criteria for DSM-IV-TR for “catatonia due to general-medical condition.” Laboratory investigations showed neutrophilic leucocytosis and ESR 30 mm/Hr. EEG done on the 9th day of illness showed generalized background slowing (4–5Hz) and right frontal epileptiform discharge. A detailed MRI study of brain showed small areas of discrete hyperintense signals (nonenhancing) in subcortical white matter in the left frontal, right parietal, and right precentral sulcal region. Lumbar CSF on the tenth day was unremarkable. CSF was negative for HSV I, II PCR, and Japanese B Encephalitis virus IgM antibody. CPK level was 562u/liter on the 3rd day of illness, 322U/liter on the 4th day, and showed a downward trend thereafter. CSF examination, repeated on the 20th day of illness, showed 20 cells/mm3 (100% lymphocytes), with other parameters being normal. By the 11th day of her illness, she had worsened, and the Bush Francis Catatonia rating score (BFCR) was 32. She was electively intubated and received intravenous lorazepam for a period of 20 days, along with sodium valproate (1,200 mg daily) and escitalopram (25 mg daily). After considering the possibility of Neuroleptic Malignant Syndrome, we administered bromocriptine 12 mg/day from the 13th to the 38th day of her illness. Clozapine 25 mg per day was added on Day 24th of illness, and the dose was gradually increased to 100 mg per day over 2 weeks. The relatives of the patient refused ECT therapy, so they were given option of experimental therapy with rTMS. The family accepted this treatment option and, after obtaining informed consent from her parents, rTMS was started Day 30th of her illness. We used Magstim Rapid2 (The Magstim Company, Ltd., Whitland, Wales, UK) to provide the rTMS therapy.
A point of motor threshold (MT) for the Abductor pollicis brevis was determined for each hemisphere. A straight line 5 cm anterior and parasagittal from that point defined the dorso-lateral prefrontal cortex. The protocol consisted of 10 cycles of stimulation at 80% of the motor threshold, which was 62% of stimulator output for her, at 10 Hz, with 2-sec train, with intertrain interval of 58 sec for 10 cycles given to right and left hemisphere on Day 1. From the 2nd to the 10th day, the stimulation was increased to 20 cycles of 20 Hz. At the end of the rTMS therapy, her BFCR score decreased significantly to 9 from previous score of 32. She started to make good eye contact, to recognize and communicate verbally with relatives, and had minimal rigidity. EEG on discharge was normal. She was discharged on tab lorazepam 1.5 mg/day, tab duloxetine 40 mg/day, tab sodium valproate 1gm/day, and tab clozapine 75 mg in two divided doses. Three months after discharge she had resumed her college studies and had no signs of catatonia. All the medications were gradually tapered and stopped. After 18 months, there were no further relapses.