Neuroleptic Induced Parkinsonism and Catatonia- A Case Report

Abstract

<h3>Introduction</h3> Neuroleptic induced Parkinsonism (commonly called EPS or extrapyramidal sideeffect) is commonly associated with use of both typical and atypical antipsychotic drugs. They may present with immobility, staring and rigidity. Catatonia is a psychomotor syndrome which is often overlooked by medical providers who consider it under the realm of psychiatric disorders such as Catatonic Schizophrenia and Depression. There are 2 subtypes described - Retarded and excited. It is also seen in various medical conditions including neurological, infectious, metabolic or drug-induced conditions and appears to be a resultant final syndrome after a cascade of events similar to the Delirium.Identifying Catatonia is very important as it is a risk factor for the development of Neuroleptic Malignant Syndrome (NMS) which carries a 10% mortality rate with clinical features indistinguishable from Malignant Catatonia. <h3>Methods</h3> Mary is a 66 yr old female with a psychiatric diagnosis of Neurocognitive disorder, remote history of schizophrenia with last exacerbation about 10 years ago with no residual symptoms who was brought to the ED by family for new onset bizarre behavior with inability to take care of self. She presented combative and disorganized in the medical ED requiring IV Haldol for behavioral control. She was subsequently admitted to the medical service for management of poor oral intake. She was seen by the Psychiatry Consult service the next day and noted to have reduced facial expression and tremors and rigidity suggestive of Neuroleptic Induced Parkinsonism. Bush Francis Catatonia rating scale was administered and she was noted to have signs of mutism, waxy flexibility, mitgehen, negativism and automatic obedience. There were periods when she was lucid and responded to questions meaningfully with brief replies. There were no features of fever and autonomic instability ruling out NMS. The possibility of Neuroleptic induced Parkinsonism along with Neuroleptic induced Catatonia was considered and organic work up was advised. The lab results were not significant for any other metabolic syndromes with exception of mildly elevated CPK. CT head was negative. The possibility of retarded subtype of Delirium was considered but patient was mute and demonstrated many of the motor signs of Catatonia. Other differentials considered were NMS, Locked-in syndrome, Abulia and Vegetative state. Haloperidol was discontinued and Mary was started on Benztropine. Over the next 2 days, there was a gradual resolution of her symptoms of EPS as well as catatonia. Naranjo possibility scale indicated probable association of Haloperidol to Neuroleptic Induced Parkinsonism. The features of Catalonia also resolved without needing the use of Benzodiazepine. <h3>Results</h3> Patient with Neuroleptic induced parkinsonism may present with symptoms similar to catatonia. Patients with Neuroleptic induced parkinsonism are more interactive and cooperative as opposed to Catatonic patients who are often withdrawn and negativistic. Tremor, which is present in parkinsonism, is not a feature of catatonia. Posturing and Echophenomena are typically absent in parkinsonism. We need to be careful to differentiate freezing seen in Parkinsonism and not mistake it for posturing. We also need to differentiate the posturing and immobility of catatonic patients from dystonia. Some patient who are treated with antipsychotic drugs may develop signs consistent with both catatonia and parkinsonism. There are very few case reports of Neuroleptic induced Parkinsonism coexisting with Neuroleptic induced Catatonia as is seen in Mary. We need to use rating scales to help differentiate and chart these symptoms on a daily basis. The mainstay of treatment for Catatonia involves the use of Benzodiazepines. There have been few reports of anticholinergics being helpful in the management of Catatonia. <h3>Conclusions</h3> Neuroleptic induced Parkinsonism can rarely coexist with Neuroleptic induced catatonia. The distinction is important as it has crucial treatment implications and misdiagnoses may occur if one is not careful. Untreated Catatonia can progress to NMS and Malignant Catatonia which lie on a continuum. The clinical picture can be complicated when the patients have other medical comorbidities including Dementia.