Beyond the Mood: Catatonia and Hippocampal Stroke in a Patient with Bipolar Disorder

Case Diagnosis: A 75-year-old female with a history of bipolar I disorder, hyperlipidemia, and prior stroke presented with altered mental status, body stiffness, and tremors, ultimately diagnosed with catatonia in the setting of a punctate left hippocampal stroke.

Case Description or Program Description: The patient was admitted with acute-onset altered mental status, exhibiting rigidity, tremors, and mutism. MRI revealed a punctate left hippocampal stroke; however, neurology did not attribute her symptoms to the stroke. Psychiatry was consulted and diagnosed catatonia, likely exacerbated by her psychiatric medications. Following discontinuation of her psychiatric regimen, her symptoms resolved, confirming the diagnosis.

Setting: Inpatient hospital admission at a tertiary care center.

Assessment/Results: The patient’s catatonia resulted in a prolonged hospital course complicated by tracheostomy placement, percutaneous endoscopic gastrostomy tube placement, urinary tract infection, pneumonia, and septic shock. Cessation of psychiatric medications including lithium and risperidone led to symptom resolution. Given the generalized deconditioning experienced by this patient, she required acute comprehensive inpatient rehabilitation after medical stabilization. This case highlights the need for careful consideration of neurological findings in conjunction with psychiatric and medication-related factors to ensure an accurate diagnosis and appropriate management.

Discussion (relevance): This case underscores the diagnostic challenge of altered mental status in patients with pre-existing psychiatric conditions as well as the interplay between neurological and psychiatric conditions in elderly patients with mood disorders. It also emphasizes the medical complications of catatonia, necessitating the need for inpatient rehabilitation to restore strength and physical function.

Conclusions: This case highlights catatonia as a rare but significant presentation in a patient with bipolar disorder and hippocampal stroke. It reinforces the need for multidisciplinary evaluation and treatment by neurology, psychiatry, and physical medicine and rehabilitation medicine in cases of unexplained neurological symptoms consistent with catatonia.