Increased biogenic catecholamine and metabolite levels in two patients with malignant catatonia
A 44-year-old man who had been diagnosed with schizophrenia at 23 years of age was admitted with symptoms of psychomotor agitation, auditory hallucinations, and emotional instability. He was prescribed chlorpromazine 150 mg/day, haloperidol 9 mg/day, biperiden 6 mg/day, carbamazepine 600 mg/day, and lithium carbonate 600 mg/day. A few months later, his psychiatric symptoms had improved, and his mood had become stable. However, on February 1, his psychiatric symptoms suddenly worsened. He developed restlessness, excitation, and paranoid thoughts. An increased dose of antipsychotics and frequent intramuscular injections of chlorpromazine and haloperidol did not improve his psychotic symptoms. He exhibited recurring episodes of stupor and excitement. On February 15, his body temperature increased to 39.5°C, his systolic blood pressure increased to 170 mmHg, his pulse rate was 120 beats per minute, and he exhibited diaphoresis. Blood analysis on February 17 revealed a serum creatine kinase level of 10,110 IU/L (normal range 46–210 IU/L) and a white blood cell count of 8,100/mm3. All antipsychotics were stopped, and fluid replacement and dantrolene 40 mg/day were started. On February 18, he was transferred to our hospital. On admission, a cerebrospinal fluid examination revealed no abnormal findings. His body temperature was 39.4°C, and he had labile blood pressure (systolic blood pressure 130–170 mmHg). He exhibited marked diaphoresis but no muscle rigidity. His serum creatine kinase value was 2,744 IU/L and his white blood cell count was 9,600/mm3. The patient received intravenous fluids and administration of dantrolene was continued.\nFrom the night of February 18, the patient showed intermittent excitement; however, repeated injections of intravenous diazepam 10 mg were ineffective. Therefore, electroconvulsive therapy was started on February 23. On March 3, after completion of five electroconvulsive therapy sessions, his psychiatric and physical symptoms resolved.\nHis catecholamine levels were not determined in 24-hour urine samples because his high level of excitement made this impractical. However, plasma catecholamine levels were measured on the morning of February 18 when he was transferred to our hospital. This measurement revealed high levels of adrenaline (102.0 pg/mL; normal morning range <100.0 pg/mL), noradrenaline (1,672.0 pg/mL; normal morning range 100–450 pg/mL), and dopamine (128.0 pg/mL; normal morning range <20.0 pg/mL).