An undiagnosed stupor in the acute medical unit: a case of malignant catatonia.

A 45-year-old man was brought to our hospital by Ambulance having been found lying unconscious on the pavement. On admission he was obtunded with a Glasgow Coma Score (GCS) of 6 (E1, V1, M4), but maintaining his airway. He was pyrexial (temperature 38.58C) and tachycardic with a pulse rate of 106 beats per minute. His blood pressure was 142/96mmHg and capillary blood glucose 6.2mmol/l. There was no evidence of trauma or needle marks. Neurological examination revealed mildly increased tone and brisk reflexes. His pupils were 4mm, equal and reactive to light. Fundoscopy showed normal optic discs. Cardiovascular, respiratory and abdominal examinations were normal. Blood tests for full blood count, urea and electrolytes, liver function, bone profile, vitamin B12, folate, thyroid function and creatine kinase (CK) were normal. HIV, serum cryptococcal antigen, hepatitis, syphilis and mumps serology tests were negative. His c-reactive protein was 30mg/l. Toxicology screens for drugs (paracetamol, salicylates, alcohol, cocaine, amphetamines, opiates and cannabis) and heavy metals (lead, mercury and cadmium) were negative. Contrast CT and MRI brain imaging found no abnormality. He was treated empirically for meningitis and encephalitis with intravenous ceftriaxone, acyclovir and ampicillin. However, lumbar puncture opening pressure was 21 cmH2O (normal range 8–21 cmH2O) and cerebrospinal fluid (CSF) white cell count was <1, protein 0.42 g/l and glucose 3.8mmol/l (serum 5.2mmol/l). CSF PCR found no evidence of HSV, VZV or enteroviruses. His autoimmune serology, including anti-VGKC, anti-NMDA receptor, antiHu, anti-Yo and anti-Ri antibodies, ANA and ANCA, was also negative. Multiple blood cultures grew no organisms. The patient remained unresponsive and pyrexial, requiring intensive nursing and nasogastric (NG) feeding. On Day 5, as part of our workup for nonconvulsive epilepsy, a trial of intravenous diazepam (5mg) was given. Remarkably the patient became completely alert (GCS 15/15), albeit briefly (<5min) after which he reverted back to stupor. Further small diazepam boluses elicited similar responses but intravenous phenytoin and levetiracetam had no effect. His EEG, while unresponsive, was normal. Whilst awake he gave a history of depression. He took no medications. The clinical picture, fever, hypertension, tachycardia and the