Table 1 Summary of clinical course

1

Patient admitted due to staring, mutism, posturing, insomnia, gait abnormalities, and somatic delusions. Home CsA discontinued due to concern for neurotoxicity. Methylprednisolone 48 mg IV daily substituted for home prednisolone 60 mg PO daily. Empiric acyclovir, vancomycin, and ceftriaxone given for possible meningitis.

3

Temporary lysis of catatonia achieved with propofol 80 mg IV. Lorazepam challenge test (2 mg IV one-time dose) later resulted in temporary resolution of catatonic symptoms. Lorazepam 2 mg IV TID started.

4

Due to concern for malignant catatonia, lorazepam increased to 3 mg IV TID with resolution of autonomic instability.

5

Mycophenolate mofetil 500 mg IV BID started as alternative to home CsA for steroid-resistant nephrotic syndrome.

10

Lorazepam 3 mg IV TID switched to 3 mg PO TID.

12

Mycophenolate mofetil 500 mg IV BID switched to 750 mg PO BID.

14

Methylprednisolone decreased to 30 mg IV daily.

15

Mycophenolate mofetil increased to 1000 mg PO BID.

18

Lorazepam increased to 3.75 mg PO TID. Methylprednisolone decreased to 20 mg IV daily.

20

Methylprednisolone 20 mg IV daily switched to prednisone 25 mg PO daily. Mycophenolate mofetil held due to continued altered mental status.

24

Lorazepam decreased to 3 mg PO TID due to concern for psychomotor slowing and sedation.

25

Mycophenolate mofetil 1000 mg PO BID restarted due to no improvement in mental status while off this medication.

28

Quetiapine 12.5 mg PO QHS started as adjunctive treatment for catatonia and psychosis. Quetiapine titrated to 25 mg QAM + 50 mg QHS over the following 7 days.

36

Quetiapine switched to quetiapine XR 100 mg PO QHS. Quetiapine XR titrated to 300 mg PO QHS over the following 12 days.

39

Patient was increasingly interactive and no longer exhibited somatic delusions or sensory misperceptions. Psychotropic meds were lorazepam 3 mg PO TID and quetiapine XR 150 mg PO QHS.

68

Catatonic symptoms noted to have resolved. Parents believed patient was at his mental status baseline. Psychotropic meds were lorazepam 3 mg PO TID and quetiapine XR 300 mg QHS.

78

Patient was discharged home on psychotropic meds lorazepam 3 mg PO TID and quetiapine XR 250 mg PO QHS (both tapered and discontinued over the following 3 months).