Moderator: Shariff Tanious, MD, FAPA
Uzma Nawaz, DO; Madison Sokol, MD; T’Keyah Vaughan, MD
Review by: T’Keyah Vaughan, MD, MS
PGY-2 | Department of Psychiatry
VCU Health System
This case presentation describes a 41-year-old male with a past medical history significant for a 3q27.3 deletion who presented with abnormal behavior following the traumatic experience of witnessing a classmate have a seizure at work.
In the weeks following this event, the patient exhibited progressive behavioral changes, including episodes of getting out of bed to look out the window and repeatedly stepping side-to-side for several minutes. He demonstrated perseveration, decreased engagement in previously enjoyed hobbies, cessation of work attendance, and worsening sleep. He also began making unusual statements, such as “the backyard is gone.”
Initial evaluation at an outside hospital revealed severe hypertension (blood pressure 200/125 mmHg) that was difficult to control. A comprehensive workup for secondary causes of hypertension, including MRI of the head and neck, renal ultrasound, and CT imaging of the chest and abdomen, was unremarkable. At that time, his presentation was attributed to hypertensive encephalopathy, thought to be secondary to an unidentified psychiatric condition. However, his abnormal behaviors persisted following hospitalization and adequate blood pressure control with 3 blood pressure medications.
Approximately six months later, the patient presented for psychiatric evaluation. On examination, he had a Bush-Francis Catatonia Rating Scale score of 15, consistent with catatonia. Treatment with lorazepam was initiated and resulted in clinical improvement, though it was limited by intolerable side effects. The patient subsequently underwent 10 sessions of electroconvulsive therapy (ECT) and was started on mirtazapine and venlafaxine.
Following these interventions, his symptoms resolved, and he was able to return to work. He continues to receive maintenance ECT at this time.
