Tratamiento de la catatonia letal con antipsicóticos atípicos: a propósito de un caso

Mujer de 17 años de edad, sin antecedentes de interés, que ingresó en la unidad de psiquiatría por un cuadro de 4 semanas de evolución, que cursaba con mutismo, agitación e insomnio. Había sido tratada con maprotilina, risperidona y lorazepam. Durante los primeros días del ingreso se modificó el tratamiento, pero continuó el empeoramiento psíquico y físico, ya que se negaba a alimentarse. Todos los estudios complementarios estuvieron dentro de la normalidad. A las 2 semanas del ingreso se observó fiebre de 38 °C en tres ocasiones. Se cambió el tratamiento a quetiapina, y según mejoraba su estado, aparecieron una paresia de la extremidad superior derecha y disartria. Ante la posibilidad de que se tratara de un efecto adverso a la quetiapina, se decidió su retirada. Antes de alcanzar la suspensión total, su estado empeoró de nuevo, con agitación, mutismo, tricotilomanía y fiebre. Se aumentó la dosis de quetiapina (600 mg/día) y volvió a mejorar. Al alta hospitalaria fue diagnosticada de catatonia letal (CL). La evolución desde entonces ha sido muy favorable, lo que ha permitido la suspensión progresiva del tratamiento. Durante los 4 meses previos a la última consulta se ha mantenido estable sin precisar tratamiento alguno.

A 17-year-old woman, without antecedents of interest, was admitted to the psychiatric ward due to a clinical disorder consisting of mutism, agitation and insomnia for the previous 4 weeks. The patient had been unsuccessfully treated with maprotiline, risperidone and lorazepam. For the first 2 weeks after admission, the treatment was modified but the patient¿s psychic and physical status worsened, since she refused to eat. The results of all complementary investigations were normal. Two weeks after admission, the patient developed a fever (38 °C) on three separate occasions. The treatment was switched to quetiapine and the patient improved, but then dysarthria and right arm paralysis were observed. Given the possibility that these symptoms were adverse effects of quetiapine, the dose of this drug was reduced. However, before complete withdrawal, the patient developed agitation, mutism, trichotillomania and fever. The dose of quetiapine was increased to 600 mg/day with symptom remission. On discharge, the patient was diagnosed with lethal catatonia. Since then, the patient has remained asymptomatic, allowing quetiapine to be slowly reduced. During the 4 months before the last visit, the patient has remained stable and has required no treatment. Based on this case, we believe that atypical antipsychotics may be useful in the treatment of some patients with lethal catatonia. The difficulties that can be encountered in the differential diagnosis between lethal catatonia and neuroleptic malignant syndrome and the nosologic classification of these entities are discussed.