Case Report Electroconvulsive Therapy for Malignant Catatonia in Adolescence Dirk M. Dhossche, MD, PhD, Shashidhar M. Shettar, MD, Tarun Kumar, MD, and Laura Burt, RN Abstract: Malignant catatonia is a severe form of catatonia which is acute in onset, and is systemically devastating, as it is associated with fever and autonomic instability. Although rarely described in children and adolescents, malignant catatonia should feature prom- inently in the differential diagnosis of acute pediatric encephalopa- thies, as it is a treatable syndrome. The case of a 17-year-old ado- lescent with sickle cell anemia is presented. The patient developed malignant catatonia and responded dramatically to electroconvulsive therapy. Key Words: adolescents, benzodiazepines, electroconvulsive ther- apy (ECT), malignant catatonia, sickle cell anemia C atatonia is characterized by abnormalities of movement, speech and behavior, and is associated with psychotic, affective, drug-related, and various medical-neurological dis- orders. 1 Catatonia was originally described in 1874 by Kahl- baum 2 but was later incorporated as a type of dementia prae- cox or schizophrenia by Kraepelin. In the1970s, catatonia was recognized as a feature of affective disorders in adults, particularly mania. 3 Catatonia also occurs in pediatric pa- tients, 4,5 and in patients with autism. 6 Its pathophysiology is obscure. Controlled treatment studies of catatonia which satisfy current standards for evaluating therapies are lacking. How- ever, the literature consistently shows the positive effects of anticonvulsant drugs, particularly benzodiazepines and bar- biturates, and of electroconvulsive therapy (ECT), regardless of the severity or etiology of catatonia or the age of the patient. 4,7–10 In 1934, Stauder 11 described malignant catatonia as Die Todliche Katatonie, or lethal catatonia. This severe form is acute in onset, systematically devastating, and is associated with fever and autonomic instability. These patients look as if they have an infectious disease, particularly an infectious encephalopathy; however, no specific infectious process is usually found. Some patients are diagnosed with coma of unknown etiology. In such instances, prompt diagnosis and treatment with benzodiazepines and/or ECT is warranted to avoid dehydration, exhaustion, thrombosis, renal failure, re- spiratory arrest, and death. 1 Case Report Our patient was a 17-year-old African-American boy brought to the emergency room of the university hospital by his mother with bizarre behavior, motor abnormalities, and hallucinations x one month. His past psychiatric history was negative. He was an excellent student, and functioned well at home. His past medical history was significant for sickle cell anemia, pulmonary hypertension, and multiple episodes of sickle cell crisis including priapism, avascular necrosis of the hip, and arthropathy. A cousin had recently been diag- nosed and treated for psychosis. About one month previously, as he was recovering in a local hospital from mycoplasma pneumonia, he started experiencing tremors in the right arm and hand, and displaying inappropriate spells of laughter and cry- ing. He was transferred to the psychiatric ward where (continued next page) From the Department of Psychiatry, University of Mississippi Medical Cen- ter, Jackson, MS. Reprint requests to Dirk M. Dhossche, MD, PhD, Department of Psychiatry, University of Mississippi Medical Center, 2500 North State Street, Jack- son, MS 39216. Email: dr6340451@pol.net Accepted March 18, 2009. Copyright © 2009 by The Southern Medical Association 0038-4348/0-2000/10200-1170 Key Points • Malignant catatonia is a severe form of catatonia which is acute in onset and is associated with fever and autonomic instability. • Malignant catatonia should feature prominently in the differential diagnosis of acute pediatric encephalopa- thy. • Electroconvulsive therapy is a safe procedure in ado- lescent sickle cell patients, provided adequate precau- tions are taken. 1170 © 2009 Southern Medical Association