(PO-172) (PO-172) COVID-19 Catatonia: A Review and Update After One Year

Background/Significance: At least seven cases of catatonia associated with coronavirus disease 2019 (COVID-19) have been reported (Zain, 2021). We present three additional cases of COVID-19-associated catatonia.

Cases: (1) Ms. A, a 26-year-old woman with no prior psychiatric history, presented with bizarre behavior. Examination showed mutism, grimacing, stereotypies, and negativism. COVID-19 PCR was positive, though she had no other signs of infection. MRI brain and CSF were unremarkable. She responded to lorazepam and lysis of catatonia revealed psychotic mania with Cotard delusion, grandiosity, auditory hallucinations, and persecutory delusions that responded rapidly to risperidone. She was discharged at her baseline. (2) Six weeks after contracting COVID-19, Ms. B, a 27-year-old woman with a history of intellectual disability and anxiety, presented with poor oral intake, staring, intermittent agitation, and mutism. Her symptoms improved with lorazepam challenge. Psychotic mania was revealed with agitation, grandiosity, persecutory delusions, and auditory hallucinations. Brain MRI showed longstanding and unchanged global atrophy and ventriculomegaly. She improved on lorazepam, lithium, and olanzapine. (3) Ms. C, a 69-year-old woman with a history of epilepsy, was admitted with mild/moderate COVID-19 pneumonia. Examination showed mutism, immobility, and rigidity. EEG revealed generalized slowing without seizure activity. MRI brain was unremarkable. After several days of scheduled lorazepam, she returned to baseline.

Discussion: These cases add to our growing knowledge of COVID-19-associated catatonia. Notably, we believe that we have presented the second case of delayed-onset catatonia following COVID-19 infection (Zain, 2021), highlighting yet another potential long-term sequela of COVID-19. A possible mechanism is COVID-induced hyperinflammation impairing GABAergic transmission in the basal ganglia (Gouse, 2020), which correlates with the beneficial effects seen with lorazepam (a GABA agonist). Coupled with previous data showing catatonia is underrecognized in both psychiatric (van der Heijden, 2005) and general medical settings (Llesuy, 2018), and that catatonic features were prominent in previous post-pandemic neuropsychiatric syndromes such as encephalitis lethargica (Cooper and Ross, 2020), there is cause for concern that the burden of COVID-19 catatonia may be significant and underestimated.

Conclusion/Implications: Catatonia is a recognizable neuropsychiatric complication of COVID-19 which typically responds to lorazepam treatment.

References:
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Gouse BM, Spears WE, Nieves Archibald A, Montalvo C: Catatonia in a hospitalized patient with COVID-19 and proposed immune-mediated mechanism. Brain Behav Immun 2020; 89: 529–30.
Llesuy JR, Medina M, Jacobson KC, Cooper JJ: Catatonia under-diagnosis in the general hospital. J Neuropsychiatry Clin Neurosci 2018; 30(2): 145–51.
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Zain SM, Muthukanagaraj P, Rahman N: Excited Catatonia — A Delayed Neuropsychiatric Complication of COVID-19 Infection. Cureus 2021; 13(3).