Increased biogenic catecholamine and metabolite levels in two patients with malignant catatonia
The patient was an 18-year-old man with bipolar disorder. At age 14 years, he began to exhibit repeated episodes of mania followed by depression in approximately one-month cycles. His mental state was stabilized with lithium carbonate (dose 1,300 mg/day, blood concentration 0.74 mEq/L). After remaining mentally stable for 2 years, the dosage was tapered and finally discontinued. Three months after discontinuing lithium therapy, he experienced a depressive state lasting approximately 10 days. Lithium carbonate 600 mg/day was restarted, but the depressive state persisted throughout June and July. In August, the dosage was increased to 800 mg/day, but when the depressive state recurred, he was admitted to our hospital on August 12. His psychiatric condition shifted to a hypomanic state the next day, but subsided on August 30. On September 9, he suddenly became stuporous, and his temperature increased to 37.8°C. Because he was unable to eat or drink independently, he received intravenous fluid replacement, and the course of his condition was observed without administering any drugs. Blood analysis revealed a slight increase in the level of serum creatine kinase to 88 IU/L (normal range 13–70 IU/L), and an increased white blood cell count (14,000/mm3). On September 10, the patient’s body temperature was 37.8°C, and rose to 38°C on September 11–13. An antipyretic (indomethacin 50 mg) was administered intrarectally on two occasions, but did not appear to reduce the patient’s fever. An antibiotic was administered intravenously. Because his C-reactive protein level (0.006 mg/dL) on September 13 did not indicate infection, administration of the antibiotic was discontinued. He had severe diaphoresis and urinary incontinence, and his entire body trembled sporadically. At the same time, his systolic blood pressure increased to 180–190 mmHg, and his pulse rate was 100–120 beats per minute. Antihypertensive drugs such as alpha or beta blockers were not administered. On September 16, he had a fever of 38.4°C. He exhibited increased muscle tone but no muscle rigidity. On September 18, no abnormal findings were found on lumbar puncture or on abdominal computed tomography and echography. His fever persisted in the range of 37.0°C–37.8°C until October 4. His stupor improved spontaneously thereafter.\nOn September 29, a 24-hour urine sample revealed high levels of adrenaline (91.1 μg/day; normal range 3–15 μg/day), noradrenaline (168.7 μg/day; normal range 26–121 μg/day), and vanillylmandelic acid (6.5 mg/day; normal range 1.4–5.1 mg/day). On October 11, he appeared to have recovered, and levels of adrenaline (10.7 μg/day), noradrenaline (46.7 μg/day), and vanillylmandelic acid (3.1 mg/day) returned to within normal range.