(PO-131) (PO-131) Specter in the Crucible: Electroconvulsive lysis of treatment-resistant Malignant Catatonia in a patient with cochlear implant

Background: Malignant catatonia (MC) is a neuropsychiatric emergency characterized by catatonia, hyperpyrexia, and autonomic instability. Cases that are refractory or partially responsive to benzodiazepines require electroconvulsive therapy (ECT) for definitive treatment. The Food and Drug Administration and device manufacturers consider a cochlear implant a contraindication for ECT. (McRackan, 2014). There remains a dearth of literature to guide the safe and effective use of ECT in patients with cochlear implants.

Case: We present the case of a 19-year-old female, with congenital bilateral deafness, and right cochlear implant since age 2, presenting new-onset epilepsy and combativeness. The patient experienced a sub-acute onset of depressive symptoms with precipitous functional decline. After seizures were stabilized, she developed delirious mania with florid catatonic excitement. Extensive workup revealed EEG abnormalities, but negative CSF assays for autoimmune encephalitis. Imaging studies were limited due to the implant. She developed MC and only partially responded to lorazepam up to 24 mg/d with intolerance of higher doses. ECT was pursued as an emergency treatment. A bifrontal electrode placement yielded complete lysis of catatonic and mood symptoms. Our case further supports the safety and efficacy of ECT in this patient population. We also propose clinical pearls for navigating the challenges of catatonia assessment in patients with deafness.

Results: The patient was emergently treated with ECT for malignant catatonia. She received bifrontal ECT at maximum settings 3 times per week. By treatment #8 catatonia resolved, and ECT was tapered to once per week with sustained remission. By treatment #11, the patient began using the implant and by treatment #12 she transitioned to once-monthly maintenance treatment.

Discussion: A few case reports describe the use of ECT in the presence of cochlear implants (Jiam, 2020). Bifrontal electrode placement provides the maximum distance from the implants and does not affect them. The use of American Sign Language can complicate the assessment of catatonia so alternative assessment techniques and interpreter education can aid navigate these complications.

Conclusion: ECT is a safe treatment for malignant catatonia. Treatment parameters can be modified to mitigate theoretical risks. For cochlear implants, bifrontal electrode placement can safely yield adequate treatment response and preserve device functionality. Catatonia assessment through the use of an American Sign Language translator can complicate detection and appraisal of catatonic symptoms. Pragmatic strategies can minimize these complications.

Jiam NT, Li D, Kramer K, Limb CJ. Preserved Cochlear Implant Function After Multiple Electroconvulsive Therapy Treatments. Laryngoscope. 2020 Nov 30. Epub ahead of print. PMID: 33252138.

McRackan TR, Rivas A, Hedley-Williams A, Raj V, Dietrich MS, Clark NK, Labadie RF. Impedance testing on cochlear implants after electroconvulsive therapy. J ECT. 2014 Dec;30(4):303-8. PMID: 24755726.