39. The Newbie

 

        Jeremy was in the hospital for almost a month by then. He wasn’t our patient at first, but for some reason I don’t remember his care was shifted to us.

        He was a 48-year-old man with a history of schizophrenia and epilepsy admitted because of high fever, worsening of his mental status, and abnormal movements. When he arrived at the hospital he was bed-bound, speechless, and completely dependent on his aunt for everything.

It was hard to watch. He was a strong guy, and he couldn’t do anything by himself. The first time I saw him he was lying down, intermittently shaking his hands like he was seizing. He had a fixed stare, his neck was rigid and he didn’t respond to any of my attempts to talk to him. He had a feeding tube and wore diapers. Seeing someone so vulnerable was tough.

At first, they screened him for infection. And by screened I mean the whole deal. It made sense, he had a fever and worsening mental status. However, his cultures were clean, his lumbar puncture was clean, the x-ray was fine, and on it goes. They were strongly considering discharging him since they couldn’t find any problems in his labs. The only reason they didn’t was because of his aunt.

        ‘She insists he wasn’t like this at home.’ A Neurology resident told me when he was passing me the case. ‘We believe she is overestimating his functionality. No way he was completely normal a month ago. She says he ate by himself, showered by himself, everything!’

        ‘Yes, forget it. She probably didn’t see him that much.’ Neurology chief resident told me. ‘Our idea is to call neurosurgery and try some heroic measure for his epilepsy assuming he is on status epilepticus.’

        ‘What about his EEG?’

        ‘Unhelpful, but we don’t have any other ideas.’ He shrugged. ’ We are open to suggestions as a matter of fact.’

        When the rounds came that day, we didn’t come up with anything new for Jeremy, no hypothesis or ideas. Neither the next day, and the day after that. We kept trying to adjust his meds hoping something would change, but every day he was the same: fever, rigidity, and unresponsive to contact. We were almost giving up on the idea that we could do anything to help him. Until a visiting doctor unknowingly shined a light over us, the newbie. He was in his sixties, but that’s how we affectionately called anyone who was visiting.

        I don’t remember his name or even where he was from. But I remember the only phrase that came out of his mouth that day when we went to see Jeremy.

        ‘This doesn’t look like spasms to me.’ He pointed at Jeremy's fidgeting hands. ‘This reminds me of mannerisms.’

        Nobody paid too much attention at the time at his remark, but that stuck with me. It was actually interesting, what if he wasn’t seizing after all? His EEG was normal, and adjusting his anti-epileptic medication wasn’t working. What if it was something else? I felt like we were finally getting somewhere. But I didn’t know where back then.

        Afterward, I found Peter at the cafeteria.

        ‘Did you hear what the newbie said?’ I asked Peter. ‘About Jeremy.’

        ‘Oh… Actually no, I think I’ve never heard his voice. What did he say?’

        ‘He says he thinks it is mannerisms.’ Peter looked thoughtful at me. We kept eating and chatting until he clicked.

        ‘Oh my God, that’s brilliant!’

        ‘What are you talking about?’

        ‘The newbie!’ Now I looked confused. ‘It’s not neurological, it’s behavioral. Do you remember Catatonia?’ I shook my head no. ‘I wouldn’t either, but I had a case when I was a student.’

        He then began to explain to me what he was talking about and we started searching online. Catatonia was a syndrome characterized by abnormal movements, immobility, and abnormal behaviors. It can be hypoactive or hyperactive, and, when it's malignant, it can cause high fever!

        'And there are many causes. It can be caused by psychiatric causes, like his schizophrenia.’ Peter continued. ‘But it can also be caused by pretty much anything, including medication and infection.’

        ‘Wow. How come I haven’t heard of this before?’ I shrugged. 'Anyway, is there anything we can do for him?' I asked.

        'Yeah. The treatment is benzos, and sometimes Electroconvulsive Therapy.’ He stretched and got up from his chair. ‘Besides treating the underlying cause, of course. Let's go talk to Dr. Collins.'

        After discussing with her, we decided to begin treatment. The neurology department was not convinced that Jeremy had Catatonia, neither was the psychiatric department. None of them had ever seen it before. But Lucy decided to start treatment either way and see how it went.

        The next day, Jeremy stopped shaking and was lying on the bed more calmly, following my voice with his eyes. A couple of days later I was shocked to see him sitting on the bed and asking for food. His aunt was right. He wasn’t like that. And because of her determination, and because of a random visiting doctor, Jeremy left the hospital walking.

        After him, I always think of Catatonia when I see someone debilitated like that. I know, that is a bias, but I can’t help but shiver with the idea that for some people a benzo could be the only thing keeping them away from sanity.

…

Want to read more about Catatonia?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5183991/

Want to read a real case of Catatonia?

https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-018-1714-z

Clinical Board

 

Instab: instability; Tt: treatment; ECT: Electroconvulsive Therapy.