A 47-year-old acutely psychotic schizophrenic man was diagnosed with malignant catatonia. Because of a history of neuroleptic malignant syndrome (NMS), traditional neuroleptics were avoided, and the patient had been treated with reserpine for a period of 10 years. Symptomatically, severe agitation alternated with severe retardation. The syndrome progressed, despite early termination of any neuroleptic medications, to marked catatonic rigidity and dehydration. Worsening was associated with transfer to a medical intensive care unit, intubation, and subsequently a tracheostomy. Dantrolene and bromocriptine were unhelpful. Lorazepam produced muscular relaxation and resulting decreases in creatine phosphokinase levels but elicited no other improvement. Eleven bilateral electroconvulsive treatments, however, resolved the respiratory impairment and catatonia and improved the psychosis. This report highlights the efficacy of ECT in lethal catatonia despite respiratory impairment and tracheostomy.
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