|Year : 2014 | Volume
| Issue : 2 | Page : 256-257
Sudden death in a case of catatonia due to pulmonary embolism
Archana Javadekar, Neha Pande
Department of Psychiatry, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||4-Feb-2014|
Department of Psychiatry, Padmashree Dr. D Y Patil Medical College, Pimpri, Chinchwad, Maharashtra
Source of Support: None, Conflict of Interest: None
Catatonic syndrome carries relatively high mortality. One of the causes of death is pulmonary embolism. Prolonged immobility, dehydration, use of low-potency antipsychotic drugs, and electroconvulsive therapy (ECT) increase the risk of venous thromboembolism. Evaluating the risk of catatonic patients is of paramount importance. Prevention of venous thromboembolism by reducing the risk factors and relieving catatonic symptoms early is essential.
Keywords: Catatonia, pulmonary embolism, venous thromboembolism
|How to cite this article:|
Javadekar A, Pande N. Sudden death in a case of catatonia due to pulmonary embolism. Med J DY Patil Univ 2014;7:256-7
| Introduction|| |
Catatonia, as a syndrome, comprises symptoms such as motor immobility, excessive motor activity, extreme negativism, and stereotyped movements. It mainly occurs in primary mood or psychotic illness and in medical and surgical conditions such as neoplasm's, encephalitis, head traumas, diabetes, and metabolic disorders.  Since Kahlbaum coined the name "vesania katatonica" in 1874, Kraeplin began using "catatonia" for a schizophrenia subtype in 1899, and Kleist explained catatonia as a kind of extra pyramidal disorder related to the basal ganglia in 1943.  However, the cause for the emergence of catatonic symptoms remains by and large elusive.
Although catatonia is reported less frequently these days, it carries relatively high mortality. Sudden deaths in catatonic patients have been reported in the past. , Catatonic patients are particularly vulnerable to pulmonary embolism due to prolonged immobile and rigid postures maintained for long hours and inability to verbalize symptoms. Prolonged immobility, food refusal, and dehydration may predispose these patients to various complications such as aspiration pneumonia, thrombophlebitis, pulmonary embolism, etc.  In addition, antipsychotic drugs are associated with greater risk of venous thromboembolism.  Association between conventional antipsychotic drugs and venous thrombosis (VTE) is well studied.  Pulmonary embolism is a dramatic and tragic complication of catatonia. In more than 95% of cases, pulmonary embolism arises from deep vein thrombus.  We report a fatal case of acute pulmonary embolism in catatonia.
| Case Report|| |
A 50-year-old woman with family history of schizophrenia was admitted for complaints of mutism, food refusal, and remaining in bed for most of the time, for 5 days. She was not on any medication prior to admission. Her medical and obstetric history was unremarkable. She had not used oral contraceptive pills. Mental state revealed a mute woman with marked psychomotor retardation and negativism. A diagnosis of catatonic syndrome was made. She was treated with 30 mg of trifluperazine, 6 mg of lorazepam, 4 mg of trihexyphenidyl, and electroconvulsive therapy (ECT). Her hydration was maintained by using intravenous fluids and later by nasogastric tube feeding. Physical examination was normal. Laboratory investigations revealed normal hemogram, urine, serum electrolytes and ECG
She received three ECTs on day 2, 4, and 6. After the ECTs, she showed some improvement in the form of acceptance of feeds and monosyllabic responses to questions. Patient did not have fever, leg pain, or fluctuations in blood pressure during hospitalization. On the 7 th day of hospitalization, she stepped out from the bed early morning and collapsed. Resuscitation efforts failed. Autopsy showed bronchopneumonia and bilateral thromboemboli.
| Discussion|| |
Under 50 years of age, women have lesser frequency of pulmonary embolism than men, but the frequency increases and is equal for sexes after 50 years of age.  Pulmonary embolisms in catatonic patients may be the result of multiple factors.  Food refusal due to negativism is a common symptom in catatonic patients. Poor oral intake leads to dehydration and hemoconcentration, thus increasing the risk of deep vein thrombosis (DVT),  which is most likely in this case. Use of low-potency first-generation drugs such as phenothiazines elevates the risk of VTE. Biological mechanisms involved in the pathogenesis of this adverse reaction are largely unknown, but several hypotheses such as sedation, enhanced platelet aggregation, and increase level of antiphospholipid antibodies have been suggested.  Treatment with phenothiazines may add to the risk as these medications increase platelet aggregation in vivo.  Inability to report symptoms results in DVT to remain undetected. Succinylcholine-induced convulsive movements during ECT may mobilize the deep vein thrombi and may prove fatal due to pulmonary embolism. Catatonic stupor predisposes patients to pneumonia because of failure to clear respiratory secretions and aspiration of stomach content.  Not only catatonic stupor, but also the catatonic excitement may prove fatal. 
Our patient had no signs of dehydration as she was fed through nasogastric tube. She had severe motor retardation. Treatment included trifuperazine and modified ECT. All these factors increased the risk of DVT. It is known that acute medical events usually occur after 2 weeks of catatonic symptoms, particularly after patients resume ambulation, more often after waking up in the morning.  Our patient with symptoms died shortly after getting up from bed in the morning following prolonged immobility for 12 days.
Prevention of DVT in catatonic patients is ensured by reducing the risk factors. Measures like maintaining adequate hydration, prevention of thrombophlebitis by exercise, graded compressive stocking, intermittent pneumatic compression/boots, or low dose of heparin,  and quickly relieving catatonic symptoms by benzodiazepines or ECTs  are of immense importance. There is a need to formulate guidelines for use of low-dose heparin in catatonia.
| Conclusion|| |
Early detection and prompt treatment of DVT is essential to prevent embolism. Perhaps evaluating the risk of pulmonary embolism in catatonic patients is very important as it is easier and less expensive to prevent pulmonary embolism than to diagnose and treat it. The uses of conventional and low-potency antipsychotic drugs are known to increase platelet aggregation and thereby increasing the risk of VTE which should be avoided in schizophrenia.
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