Benzodiazepines in catatonia associated with systemic lupus erythematosus
Tiao-Lai Huang, MD, Department of Psychiatry, Chang Gung Memorial Hospital–Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta-Pei Road, Niao-Sung, Kaohsiung 833, Taiwan. Email: email@example.com
Abstract Neuropsychiatric disturbances are found in 50–70% of systemic lupus erythematosus (SLE) patients. However, there are rare cases of catatonia being described in SLE. Some studies have shown the effectiveness of high-dose steroid, plasma exchange and electroconvulsive therapy (ECT) in lupus catatonia. Herein are described two SLE patients with catatonia who had good response to i.v. diazepam (i.e. relief of catatonia symptoms). Patient 1, with mild cortical atrophy, had great improvement in catatonia symptoms on i.v. diazepam 150 mg during a period of 5 days. Patient 2, without cortical atrophy, had quick response to i.v. diazepam 10–20 mg. Both patients had no recurrence during 6-month follow up. In conclusion, benzodiazepines may play an important role in the treatment of catatonia associated with SLE if patients refuse ECT treatment.
Catatonia can be caused by a variety of metabolic, neurological, psychiatric, toxic and medical conditions.1–4 According to the DSM-IV criteria, catatonia is characterized by stupor, excitement, negativism, mutism and catalepsy, together with rigidity and waxy flexibility.5 Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystemic involvement. Neuropsychiatric disturbances, ranging from cognitive dysfunction, neuropathy, headache, convulsion, psychosis, mood disorders, and delirium to life-threatening coma were found in 50–70% of SLE patients.6,7 There are rare cases of catatonia described in SLE.8–12 These aforementioned cases illustrated the effectiveness of high-dose steroid (up to methylprednisone 1 g/day for three days) followed by plasma exchange six times, steroid alone, or five sessions of electroconvulsive therapy (ECT) in SLE patients with catatonia. Huang, and Hung and Huang reported that a modified treatment strategy with benzodiazepines could rapidly and completely relieve catatonic signs in patients with schizophrenia and major depression.13,14 Other studies also showed that benzodiazepines is effective for catatonic signs.15–17 Here, we describe two SLE patients with catatonia who had good response to i.v. diazepam in relieving catatonic symptoms and discuss the role of benzodiazepines in catatonia of SLE, if patients refuse ECT.
A 19-year-old woman had a 2-year history of SLE and regularly received prednisolone 40–60 mg/day. Because stupor, mutism, negativism, refusal to eat and motor retardation were noted for 5 days, she was admitted to Chang Gung Memorial Hospital. Treatment was commenced with oral prednisolone 30 mg daily and was increased to 45 mg/day 2 days later. During hospitalization, laboratory work-up for active SLE showed a normal blood count and differential, negative anti-dsDNA antibodies, and normal serum C3 and C4 complements. Brain computed tomography (CT) showed mild cortical atrophy. The patient did not undergo lumbar puncture. Electroencephalogram (EEG) examination was normal. Physical examination showed no other signs of lupus flares. Due to the persistence of the catatonic state, psychiatrists were consulted and they confirmed the presence of catatonic features. The patient was prescribed oral lorazepam 4 mg daily for 2 weeks. Because the clinical condition did not improve, 10 mg diazepam i.v. drip in 500 mL normal saline was given three times daily. The catatonic features resolved gradually over 5 days (total 150 mg diazepam) and the patient regained the ability to speak meaningfully, walk, eat, and obey orders. The patient had no recurrence during 6-month follow up on benzodiazepines and prednisolone.
A 24-year-old woman had a 2-year history of SLE and did not regularly receive prednisolone treatment. She presented with catatonic features including mutism, stupor and negativism for 4 days. The patient arrived at the emergency unit and the aforementioned symptoms improved immediately after receiving 10 mg diazepam i.v. twice within 1 h (total 20 mg). The patient was then discharged. However, 3 days later, the patient had a relapse of motor symptoms and received inpatient treatment. During hospitalization, brain magnetic resonance imaging (MRI) was normal. Laboratory work-up for active SLE showed a normal blood count and differential and normal serum C3 and C4 complements. The patient did not undergo lumbar puncture or EEG examination. On day 2, psychiatric consultation confirmed the diagnosis of catatonia. Mental status examinations indicated stupor, mutism and catalepsy. Oral lorazepam 4 mg and prednisolone 20 mg per day were given for 2 days, with no response. Then 10 mg i.v. diazepam stat was given and the catatonic features resolved. The patient could obey orders, eat and speak. The patient had no recurrence of catatonia during 6-month follow up on benzodiazepines and prednisolone.
Patient 1 had no response to oral lorazepam (total 56 mg) but had good response to i.v. diazepam (total 150 mg). This phenomenon was also noted in other reports.13,15–19 In contrast, patient 2’s catatonia responded quickly to i.v. diazepam. Bush et al. found that parenteral and/or oral lorazepam is effective in 76% of subjects with acute catatonia.16 We had further found that i.m. lorazepam and i.v. diazepam produced high success rates in catatonia-associated schizophrenia and major depression, with response rates up to 100%.13,14 In the present study we also found that i.v. diazepam could be effective in treating catatonia of SLE. In addition, we found that higher dose of benzodiazepines could also play an important role in the treatment of catatonia in SLE, as in other organic catatonias.20,21
In past studies, rising seizure threshold was hypothesized to explain the benefit of barbiturates, anticonvulsants, benzodiazepines and ECT in treating catatonia.22,23 Recently the γ-aminobutyric acid hypothesis has been suggested to explain the main mechanism of catatonia.24 Although the detailed mechanism of benzodiazepine in catatonia associated with SLE remains to be clarified, the present report demonstrates benzodiazepines to be safe, quick and effective in relieving catatonia associated with SLE and to prevent further complications.