Catatonic syndrome as the presentation of encephalitis in as
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A 43-year-old woman was brought to the emergency department suffering from stupor, silence and staring. Three days prior, her husband noticed that the patient had apathy, slow thinking and decreased mobility. On presentation to the emergency department, her heart rate was 110 beats per minute. Neurological examination revealed stupor, muteness, fixed gaze, negativism, stiffness in the left hemibody, gegenhalten sign on the right side of the body, global hyperreflexia and no neck stiffness.

The Bush-Francis Catatonia rating scale was 19 points. The approach was based on catatonic syndrome. Initially, a CT scan of the head was requested without alterations. An electroencephalogram (EEG) showed generalised slow activity. Even during the EEG, the patient had motor stereotypes that did not correlate with brain activity. Initial blood test reported a white cell count of 9.5×109, C reactive protein of 5.7 mg/L. Serum electrolytes, creatine phosphokinase, the liver and renal functions were normal, and thiamine levels were unremarkable. Lumbar puncture revealed an opening pressure of 17cm H2O. The white blood cell count in the cerebrospinal fluid (CSF) was 16 mm3 (100% lymphocytes). Treatment with acyclovir for the probable viral encephalitis and a diazepam infusion for the catatonic syndrome was started.

On day 2 of admission, she had a cough, a fever of 102.92°F (39.4°C), and 88% oxygen saturation on pulse oximetry. On examination, chest auscultation was normal. CT of the chest showed basal bilateral pulmonary infiltrate. A serum IgG, IgM and a nasopharyngeal swab PCR test for the SARS-CoV-2 was performed.

CSF cytology was normal. The direct Gram stain of the CSF and CSF culture was negative, and PCR was negative for herpes virus (HSV) type 1 and 2. MRI of the brain showed no abnormalities.

The approach was then focused on autoimmune aetiology, and she was treated empirically with a bolus of methylprednisolone 1 g per day for 5 days.

On day 3 of admission, she presented with orofacial dyskinesias, upper limb stereotypies and waxy postures. A thyroid nodule was detected with standard thyroid tests, antiperoxidase antibodies, and antithyroglobulin antibodies were negative. The histological report of the thyroid nodule was lymphoid hyperplasia.

Serum IgG and IgM and PCR were positive for SARS-CoV-2; the patient presented mild typical respiratory symptoms. The catatonic syndrome was related to encephalitis in association with COVID-19.

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