MHGCJ – 2021
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Clinical case of catatonic stupor developed as a
result of acute respiratory disease COVID-19
Komarovskyi М. S., Mykytenko R. V., Onofreichuk Kh. О., Hryshchenkova О. S.,
Podhorna А. D., Kosolapov О. P., Zolotarov P. V.
Starokostiantyniv Military Hospital. Starokostiantyniv, Ukraine
Abstract
The aim of this work is to demonstrate and analyze a clinical case of catatonic stupor as a
consequence of the complex effect of the infectious process, namely systemic inflammation and
direct neurotoxicity of the SARS-CoV-2 virus on the nervous system. A retrospective analysis of
outpatient and inpatient medical records was performed. Analysis of clinical case proves the
possibility of catatonic syndrome due to acute respiratory disease COVID-19. 2. Given that
catatonia is an urgent condition, it is necessary to be vigilant about its occurrence.
Keywords
COVID-19, post-infectious catatonia, mental disorders, clinical case.
Address for correspondence:
Komarovskyi М. S,.captain of the medical service, the head of the medical department.
Starokostiantyniv Military Hospital. Starokostiantyniv, Ukraine, e-mail
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Komarovskyi, Mykytenko, Onofreichuk, Hryshchenkova, Podhorna, Kosolapov,
Zolotarov, 2021
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
doi: https://doi.org/10.32437/mhgcj.v4i1.129
Introduction
Despite the fact that COVID-19 primarily
damages the respiratory system, as the pandemic
continues, the number of patients in whom the
infection affected the nervous system and
neuropsychiatric disorders such as hyposmia,
stroke, insomnia, neurotic disorders or delirium
increases. One of the potential post-infectious
disorders may be catatonia. Only sporadic cases
of it are described, and reliable data on
observations about it are absent. At the same
time, careful attention is paid to post-infectious
catatonia caused by COVID-19, because in the
absence of timely recognition and treatment of
this urgent condition there are serious
complications that can be fatal.
The aim of the work
The aim of the work is to demonstrate and
analyze a clinical case of catatonic stupor of post-
infectious origin due to the acute coronavirus
disease COVID-19 in patient P., 40 years old, who
from 25.03.2021 to 30.04.2021 underwent
examination, treatment and rehabilitation in
Starokostiantyniv military hospital.
Materials and methods
A retrospective analysis of outpatient and
inpatient medical records was performed.
MHGCJ – 2021
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Results and discussion
Catatonic stupor is a psychopathological
syndrome characterized by immobility combined
with lack of verbal contact and increase of muscle
tone. Catatonia has traditionally been regarded
as a sign of endogenous psychosis, especially
schizophrenia. However, this syndrome is not
nosologically specific and can occur in many
diseases: up to 20-25% of its cases are
somatogenously caused (Dunaievskiy. Kuznetsov,
2019). Constantine von Economo was the first who
described catatonic syndrome after acute
respiratory disease in detail in the structure of
lethargic encephalitis, which affected some
patients after the Spanish flu during the pandemic
of 1918-1920. In May 2020, during the COVID-19
pandemic, Italian doctors were among the first to
report an atypical curative case of "akinetic
mutism". In retrospect, it was regarded as a
catatonic stupor (Cooper, Ross, 2020). In the
same month, British doctors reported a case of
catatonia, manifested by stupor and
accompanied by disorders of perception, in a
man with COVID-19 (Caan, Lim, Howard, 2020). In
the systematic review of the literature as of
20.04.2021, in addition to the above, there are 7
more relevant cases of catatonia due to COVID-
19 (Schneider, Smith, Wohlleber, Malone,
Schwartz, 2021). The authors consider its
appearance as a consequence of the complex
impact of the infectious process, namely systemic
inflammation and direct neurotoxicity of SARS-
CoV-2 virus on the nervous system, as well as
psychosocial factors leading to post-traumatic
stress, anxiety and depression. Differential
diagnosis with hypokinetic delirium is proposed,
which in particular consists in a rapid positive
response to benzodiazepines: patients quickly,
significantly improved after their prescription,
which is not typical for delirium.
Below is our own clinical case of catatonic
stupor, which developed in a patient as a result of
COVID-19.
In the life history, the burden of heredity on
mental illnesses is remarkable: the father is
"commissioned" from armed forces after the
transferred TBI on a line of psychiatry, the aunt on
a line of the father suffers from depression. The
patient underwent regular medical examinations
during military service and was considered
healthy. At work, family and friends are
characterized positively. Patient does not smoke,
denies the abuse of psychoactive substances.
Case history: from 08.03.2021 there was a
general weakness, increased body T to 38.0 ° C.
10.03.2021 performed PCR with real-time
detection, during study of nasopharyngeal lavage
revealed RNA of SARS-CoV-2 virus. Outpatient
treatment was started: hepacef, moxifloxacin,
xarelto, pulmobriz, serrata, vitamin therapy, tonic
therapy, physiotherapy. D-dimer from 12.03.2021
103.0 ng FEU / ml. CT of the chest from
16.03.2016: "CT signs of viral pneumonia. High
probability of COVID-19. CT-I (area of the affected
parenchyma up to 15%)". Antibiotic therapy was
continued. Feelings began to improve, the body's
T decreased, staying in the range of 35.9-36.5 ° C.
From 21.03.2021 due to the fact that the condition
was regarded as recovery, treatment was
canceled.
During the illness there was a pronounced
somatopsychic asthenia, in particular, weight loss
of 7 kg, complained of fatigue, patient was weak,
lethargic, anxious, suspicious, for example, many
times a day measured the saturation of oxygen in
the blood. Despite the improvement in somatic
condition, general weakness, fatigue and anxiety
aggravated. Obvious changes in mental status
from 22.03.2021: he spoke in a quiet, hoarse
voice, became retarded, tense, reacted
sluggishly to others, decreased appetite, and
almost stopped sleeping at night. On March 23,
2021, due to the expiration of the term of
outpatient treatment, he tried to start military
service, due to severe asthenia; his release from
duty was extended. On March 24, 2021,
stereotypical movements appeared the patient
stared straight ahead, could not pay attention to
anything. 25.03.2021 consulted a psychiatrist,
recommended MRI of the brain. In the process of
preparation for MRI in the X-ray room finally
stopped moving, did not respond to painful stimuli,
and did not respond to the spoken language. MRI
of the brain from 25.03.2021: "MR data for the
presence of changes in the volume of the
substance in the brain at the time of the
examination was not detected. MR signs of focal
process of the brain, most likely against the
background of neuroinfection. Hospitalization with
a diagnosis of catatonic syndrome is
recommended. On admission to the hospital,
examined while lying on a couch, his face tense,
with his eyes tightly closed, he resisted the attempt
to open them. On the language, painful stimuli did
not respond; muddy. He showed waxy flexibility in
the muscles of the upper extremities, there were
elements of passive submission: he allowed
himself to sit on the couch, stuck in this position with
his arms outstretched. Body T = 37.4 ° C, blood
pressure = 130/100 mm PC, Ps = 120 / min., Sp
O2 = 97%. Laboratory tests within normal limits
(leukocyte count 7.9 x 109 cells / l). Delivered to
the department on a stretcher. Introduced solution
of Diazepam 5 mg / ml 4.0 ml v./m. About 30
minutes after the injection of Diazepam, opened
MHGCJ – 2021
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
his eyes, followed the interlocutor's gaze,
responded to the spoken language, and made
verbal contact. The patient answered in terms of
the respondent, but in one word, in a quiet, low-
modulated voice. Attention is unstable,
exhausting. Oriented comprehensively enough,
productive psychotic symptoms, gross cognitive
impairment did not show. Patients followed the
instructions as much as possible. According to the
Bush-Francis catatonia scale, the patient scored
20 points, which convincingly indicates the
presence of catatonia. Subsequently, on the
background of treatment and rehabilitation, the
patient's condition continued to improve, followed
by discharge in a state of stable compensation.
Conclusions and suggestions
1. Analysis of the above clinical case proves
the possibility of catatonic syndrome due to acute
respiratory disease COVID-19. 2. Given that
catatonia is an urgent condition, it is necessary to
be vigilant about its occurrence. Based on this
case, it is necessary to consider the possibility of its
occurrence not only at the height of the infectious
process, but also as it resolves, i.e. to show
increased vigilance to convalescents and not
leave them unaccompanied in outpatient and
family medicine. If catatonic stupor is suspected,
it should be diagnosed with other similar
conditions, including hypokinetic delirium, taking
into account the difference in subsequent
treatment tactics. Patients with pre-existing
psychiatric pathology are likely to be at risk,
especially if catatonic syndrome is present. It is
possible that the development of catatonia in the
patient described by us contributed to the burden
of heredity in psychiatry, which was realized after
the transferred somatopsychic extreme factor. 3.
Prevention of anxiety among the population
should be carried out, as the neurotization of
society on the background of a pandemic comes
up with to the emergence of mental disorders.
Obviously, that the characterological anxious
thinking of the patient, considered in the clinical
case, in stressful conditions was one of the factors
that led to the deterioration of the mental state.
Conflict of interest
The author declares that she has no conflict of
interests.
References
Dunaievskiy V.V., Kuznetsov A.V. (2019). Catatonia
evolution of views and modern concepts
(literature review) . Review of psychiatry and
medical psychology. 4-2:29-40.
Cooper, J. J., Ross, D. A. (2020). COVID-19
Catatonia – Would We Even Know? Biological
Psychiatry, 88 (5), e19-e21.
Caan, M. P., Lim, C. T., Howard, M. (2020). A Case
of Catatonia in a Man With COVID-19.
Psychosomatics, 61, 556-560.
Schneider, N. S., Smith, A. K., Wohlleber, M.,
Malone, C., Schwartz, A. C. (2021). COVID-19
and Catatonia: A Case Series and Systematic
Review of Existing Literature. Journal of the
Academy of Consultation-Liaison Psychiatry.