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Wang and Huang state that although neuropsychiatric disturbances are found in 50–70% of patients with systemic lupus erythematosus (SLE), cases of catatonic symptomatology are rare.1 They describe successful use of benzodiazepines in management of catatonic symptoms in SLE and cite five references supporting the association of catatonic symptomatology with SLE.2–6 We would like to add a few more reports from the literature illustrating the association of catatonic symptoms with SLE.7–20

SLE with ‘secondary’ catatonia was described in ‘. . .  151 cases of needle biopsy of the lung in diffuse parenchymal disease’ by Youmans et al. in 1970.7 In 1972, Ismailov and Frumkina described two cases of symptomatic psychosis in SLE with catatonic symptoms, with continuous shift of affective and catatonic symptoms.8 In 1980 Pilz et al. reported the presence of catatonic symptoms in a 28-year-old man 6 months before he died.9 Lichtenstein et al. remind us that the psychiatric manifestations of SLE and other autoimmune diseases may precede by many years the systemic involvement, and the fact should be held in mind by both the internist and psychiatrist.10 They reported a case of a female catatonic patient without metabolic disturbances, where immune complexes were demonstrated in cerebrospinal fluid.

Miguel et al. (1990) conducted a prospective study on the psychiatric aspects of SLE.11 Out of their 23 patients, 12 showed psychiatric symptoms. The cognitive symptoms were the most prominent, followed by affective, catatonic and hallucinatory features.11,12 Fricchione et al. in 1990 and Ditmore et al. in 1992 described the use of electroconvulsive therapy (ECT) in the treatment of catatonic symptoms in severe SLE.13,14 Similarly, in 2001 Malur et al. describe the successful use of ECT in prolonged catatonia in three patients, of whom one had SLE.15

Because antipsychotics (e.g. chlorpromazine), carbamazepine and lithium carbonate can cause catatonic symptoms as well as SLE-like syndrome, it is important to choose the medication carefully.16 Apart from treatment with benzodiazepines and ECT, treatment of the SLE by corticosteroids,3,6 immunosuppressive agents3 (e.g. cyclophosphamide)16 and plasma exchange2,17 is helpful.

In 2001 Ampelas et al. indicated that psychiatrists should be mindful of SLE and primary Sjogren's syndrome as potential causes of multiple unexplained somatic complaints and psychiatric symptoms.16 They recommended a search for autoantibodies in serum in the case of clinical suspicion, after completing a careful physical examination, to confirm the diagnosis.16 Munoz-Malaga et al. in 1999 stated that it is important to maintain a high suspicion of SLE in acute psychotic patients, especially if atypical features are present, and they argued for the study of lupus band in skin biopsy for these patients, regardless of the absence of anti-ribosomal antibodies.17

The association of catatonic symptoms in SLE demonstrates that catatonic disorder due to general medical conditions should be considered in every patient with catatonic signs,21,22 It also illustrates the importance of avoiding antipsychotic medication for catatonic symptoms and instead treating catatonia with benzodiazepines and ECT while focusing on treatment of the underlying condition. Clearly, it is helpful to have a hierarchy of treatment options for those patients with catatonia who do not respond to benzodiazepines and/or ECT.23

REFERENCES

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  2. REFERENCES
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    Wang HY, Huang TL. Benzodiazepines in catatonia associated with systemic lupus erythematosus. Psychiatry Clin. Neurosci. 2006; 60: 768770.
  • 2
    Perisse D, Amoura Z, Cohen D et al. Case study: Effectiveness of plasma exchange in an adolescent with systemic lupus erythematosus and catatonia. J. Am. Acad. Child Adolesc. Psychiatry 2003; 42: 497499.
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    Lanham JG, Brown MM, Hughes GR. Cerebral systemic lupus erythematosus presenting with catatonia. Postgrad. Med. J. 1985; 61: 329330.
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    Youmans CR, DeGroot WJ, Marshall R, Morettin LB, Derrick JR. Needle biopsy of the lung in diffuse parenchymal disease. Am. J. Surg. 1970; 120: 637643.
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    Ismailov TI, Frumkina SL. Psychopathology and pathogenesis of symptomatic psychosis in systemic lupus erythematosus. Zh. Nevropatol. Psikhiatr. SS Korsakova 1972; 72: 18601864.
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    Pilz P, Wallnofer H, Klein J. [Thrombophlebitis of internal cerebral veins in a case of systemic lupus erythematosus]. Arch. Psychiatr. Nervenkr. 1980; 228: 3143.
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    Lichtenstein A, Calish I, Oliveira RM, Miguel Filho EC, Rocha AS. Catatonic syndrome caused by autoimmune disease: Spontaneous remission. Rev. Hosp. Clin. Fac. Med. Sao Paulo 1989; 44: 312315.
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    Ahuja N. Organic catatonia: A review. Indian J. Psychiatry 2000; 42: 327346.
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    Carroll BT, Goforth HW, Thomas C et al. Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes. J Neuropsychiatry Clin. Neurosci. 2007 (in press).