Cases That Test Your Skills

An overlooked cause of catatonia

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Ms. L’s clinical presentation most likely implicated VZV. Skin lesions of VZV may look exactly like HSV, with clustered vesicles on an erythematous base (Figure5). However, VZV rash tends to follow a dermatomal distribution (as in Ms. L’s case), which can help distinguish it from herpetic lesions.

Varicella-zoster virus with clustered vesicles on an erythematous base

Cases of VZV infection have been increasing worldwide. It is usually seen in older adults or those with compromised immunity.6 Significantly higher rates of VZV complications have been reported in such patients. A serious complication is VZV encephalitis, which is rare but possible, even in healthy individuals.6 VZV encephalitis can present with atypical psychiatric features. Ms. L exhibited several symptoms of VZV encephalitis, which include headache, fever, vomiting, altered level of consciousness, and seizures. An EEG also showed intermittent generalized slow waves in the range of theta commonly seen in encephalitis.

Ms. L’s case shows the importance of early recognition of VZV infection. The diagnosis is confirmed through CSF analysis. There is an urgency to promptly conduct the LP to confirm the diagnosis and quickly initiate antiviral treatment to stop the progression of the infection and its life-threatening sequelae.

In the absence of underlying medical cause, typical treatment of catatonia involves the sublingual or IM administration of 1 to 2 mg lorazepam that can be repeated twice at 3-hour intervals if the patient’s symptoms do not resolve. ECT is indicated if the patient experiences minimal or no response to lorazepam.

The use of antipsychotics for catatonia is controversial. High-potency antipsychotics such as haloperidol and risperidone are not recommended due to increased risk of the progression of catatonia into neuroleptic malignant syndrome.7

Continue to: OUTCOME Prompt recovery with an antiviral


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