the clinical suspicion of catatonia . 1 , 19 She received points for immobility / stupor ( 2 , virtually no interaction with external world ), mutism ( 3 , no speech ), staring ( 2 , gaze longer than 20 seconds with some shifting attention ), posturing / catalepsy ( 2 , 1-15 minutes ), rigidity ( 2 , moderate ), negativism ( 2 , moderate resistance or contrary ), no oral intake for greater than one day ( 3 ), Gegenhaltan , which is resistance to passive movement that does not appear willful ( 3 ), and autonomic abnormality ( 1 , diaphoresis ). This constellation of clinical and imaging findings in this case demonstrates , for the first time to our knowledge , that catatonia can be associated with TL in the setting of buprenorphine use .
Scheduled lorazepam , or in refractory cases , ECT , are considered the standard treatments for nonmalignant catatonia ; however , the response rates vary significantly . 21 A lorazepam challenge may be helpful in diagnosing catatonia as sometimes symptoms will be relieved after giving intravenous lorazepam . 22 However , in this case , the patient did not respond to the administered lorazepam . Across the literature , there are varying response percentages to lorazepam ranging from 30 to 80 %, with features like mutism being poor prognostic indicators for responsiveness to the challenge . 21 – 23 The patient presented here did have mutism as a symptom . If the lorazepam challenge does abate symptoms , then treatment would continue with scheduled lorazepam . 24 In cases that do not respond to lorazepam , ECT is another option for treating catatonia with the goal of treatment being complete symptom resolution . 20 , 25 ECT can especially be helpful in patients who are pregnant or postpartum . 24 , 26 , 27 Combining both treatments can also be used to treat catatonia . 1 , 20 , 24 – 26 In the case where these options do not yield success , supportive care , including fluid rehydration , withdrawal symptom treatment , and addressing autonomic changes in heart rate and blood pressure , can be utilized . 25
There were several limitations in diagnosis . Our diagnosis is a clinical and radiological one . There was no formal Bush Francis catatonia scale performed in real-time during the patient assessment . However , most of the symptoms comprising the scale were assessed and extensively documented by multiple examining physicians , and the scale was performed based on EMR review . With the delayed urine drug sample , it is hard to exclude interaction with benzodiazepines , though the clinical administration of them in the emergency department can reasonably account for this . Additionally , her history included an exposure to buprenorphine or “ subs ” as it was termed . Though we cannot rule out benzodiazepine exposure completely , we lean toward veracity in the patient history as well as the reasonable explanation of positivity given benzodiazepine administration in the emergency department . Furthermore , she had positivity for buprenorphine on admission at her child ’ s birth two weeks prior and was negative for benzodiazepines at that time with blood screening suggesting she may not have been utilizing benzodiazepines .
Catatonia has several differential diagnoses that must be considered , including akinetic mutism , neuroleptic malignant syndrome , and serotonin syndrome , among others . 1 , 28 , 29 Akinetic mutism has features of catatonia , including mutism and immobility , but is predominantly associated with findings of brain lesions in the pre-frontal or frontal cortex . 13 , 28 , 30 This patient has no such findings . Additionally , the patient had symptoms of negativism , which is not typically seen with akinetic mutism . 28 , 30 Neuroleptic malignant syndrome and serotonin syndrome both have objective findings of hyperthermia and autonomic instability not appreciated in this patient . 31
Heroin-induced leukoencephalopathy is also included in the differential diagnosis . However , as mentioned previously , these patients typically progress through three stages of illness to include symptoms of cerebellar ataxia , confusion , extrapyramidal symptoms , spastic hemiplegia or quadriplegia , generalized motor deficits , and unresponsiveness . 12 These symptoms present step-wise typically over a course of weeks to months ultimately leading in death . 7 , 12 , 32 Akinetic mutism and areflexic paresis typically happen at the end of the symptom course , weeks after the onset of symptoms . 32 The patient was not positive for any other opioids on admission , and she was last seen normal five hours prior to admission , making the course of events less likely to line up with heroin-induced leukoencephalopathy .
Ruling out post-partum catatonia completely is difficult as well , though the evidence points to substance induced rather than post-partum catatonia given the acuteness of her recovery . Post-partum catatonia has been reported only a handful of times in the literature and is typically superimposed on a mood disorder , for which this patient had no history . 26 Collateral information retained indicated that the patient ’ s mood was normal without features concerning for depression or mania and that the patient was motivated to work on obtaining custody of her child . Catatonia in the post-partum period is typically associated with mania , and she did not exhibit
26 , 27 signs of mania at the time .
Demand for treatment of opioid use disorder includes increased access to buprenorphine with prescribing facilities quadrupling since 2003 , and the United States ’ capacity to treat over 3.6 million patients with buprenorphine . 33 West Virginia ( WV ) had the second highest total buprenorphine maintenance treatment prescriptions nationwide per 1,000 Medicaid enrollees ages 12 years and older in 2018 . 34 This figure is more than six times higher than the national average and has increased by 393 % since 2014 . 34 WV has continued to try to answer increased demand by increasing buprenorphine availability . 35 With increasing use , physicians are more likely to encounter uncommon adverse effects such as the one presented in this case . For providers prescribing buprenorphine , or physicians in acute care settings likely to encounter these patients , prompt identification and treatment of these adverse effects is needed to prevent complications . Therefore , recognition of buprenorphine associated TL with catatonia is crucial for physicians to better care for these patients .
CONCLUSION
Given the prevalence of buprenorphine use in WV , it is important to maintain a high degree of suspicion for development of TL in adult patients with acute onset catatonia . Patient education with proper usage of this medication remains a cornerstone in caring for patients with opioid use disorder .
28 • www . wvsma . org