وبلاگ آموزشي و پژوهشي روانپزشكي

Case presentation

A 45-year-old married Persian white male who was a retired printing house worker presented with refusal to eat and drink, mutism and lack of response to external stimuli and was taken to a psychiatric center by his family members. He was suffering from sleep disturbance and lack of appetite from two months earlier subsequent to self burning of one of his child. His other child was attending the military service and this is an additional stressful event for him .also as his family stated he had been indifferent to his life affairs for a long time. Besides he had a history of problem in defecation (constipation) and abdominal pain for several years. One week before hospital admission, he gradually became stuporous and mute. History of cigarette smoking, drug abuse and alcohol consumption was negative. He had a prior history of taking part in war, 23 years ago and in his family history, one of his child and his sister were under treatment because of mental retardation and mood disorder respectively. Patient’s weight and height were 65 kgs and 168 cm respectively. Regarding mentioned symptoms and signs, it was impossible to take a history from the patient and do physical examination until 48 hours after initiation of treatment.

Therefore, with possible diagnosis of catatonia, Lorazepam  3 mg through nasogastric tube was prescribed. 48 hours after receiving Lorazepam, a marked improvement in catatonic features was seen. His motor ability improved and he was able to give relevant answers to the questions. In clinical interview and physical examination, delusion, hallucination, major depression symptoms and signs and disturbance of consciousness were not detectable and schizophrenia, major depression and delirium as possible causes of catatonic syndrome were ruled out. Considering patient’s occupation (printing-house worker), complete physical examination was performed. After we did physical examination, it became clear that he has been suffering from fingers’ paraesthesia. Other parts of general physical examination including head and neck, heart and lungs, abdominal, extremities are all normal. in the neurologic examination MMSE score in registration, 3 stage command, reading, writing, and copying was abnormal (21 of 30) and go/no go test was impaired, other components on neurologic examination including cranial nerve, motor, sensory, cerebellar and gait (which is done carefully by a neurologist) were normal. In Para clinic study, neuropsychology test showed dysfunction in frontal lobes and in the study of PBS, toxic granulation (Figure 1), Dohle body (Figure 2), and basophilic stippling (Figure 3) were seen. (In order to detect basophilic stipplings more efficiently, RBCs were packed with micro hematocrit method and after Wright-Gimsa staining, these cells were seen more clearly).

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Toxic granulation.

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Dohle body, and basophilic stippling.

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Basophilic stippling.