Case presentation

A 58-year-old man with diabetes and human immunodeficiency virus presented to the emergency department in a state of acute catatonic rigidity, with the inability to speak, and the inability to relax his upper and lower limbs with gravity. Bedside glucometry revealed a blood sugar level of 29 milligrams per deciliter. These symptoms had never occurred before, and had started prior to ED arrival while walking outside. Laboratory investigations were unremarkable, with computed tomography of the head revealing no acute findings other than chronic ischemic changes. After the administration of dextrose, the patient returned to his baseline status with a normal physical exam, and was admitted for further glycemic tailoring.

Figure 1: Posturing & catalepsy seen in catatonia.

Description

Catatonia has been described as the inability to move parts of the body with normal function [1]. The dysfunctions may include stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, and echopraxia [1]. A combination of these symptoms have been described in various psychiatric and medical syndromes, including mania, mood disorders, schizophrenia, and metabolic disorders. Although most associations between hypoglycemia and catatonia have described catatonia as the underlying cause of hypoglycemia in the setting of poor nutritional intake, there is very limited literature describing hypoglycemia as the underlying cause of catatonia. The novel presentation of this case can remind clinicians that although rare and mostly due to psychiatric illness, unexplained catatonia in a patient without psychiatric illness may be due to hypoglycemia; The Great Mimicker. This is important, given the risk of fatal arrhythmias, loss of consciousness, and seizures associated with hypoglycemia [2,3]. In this case, acquiring bedside glucometry on arrival permitted prompt diagnosis and treatment.

References

1. Tandon R, Heckers S, Bustillo J, et al. Catatonia in DSM-5. Schizophrenia Research. 2013; 150: 26-30.
2. Puente EC, Silverstein J, Bree AJ, et al. Recurrent Moderate Hypoglycemia Ameliorates Brain Damage and Cognitive Dysfunction Induced by Severe Hypoglycemia. Diabetes. 2010; 59: 1055-1062.
3. Reno CM, Daphna-Iken D, Chen YS, VanderWeele J, Jethi K, et al. Severe Hypoglycemia-Induced Lethal Cardiac Arrhythmias Are Mediated by Sympathoadrenal Activation. Diabetes. 2013; 62: 3570-3581.