Acute Catatonia Associated with Hypercalcemia and Hyperparathyroidism: A Case Report and Literature Review

Abstract:

Background: Hypercalcemia has been associated with neuropsychiatric symptoms including mood and cognitive changes, and infrequently psychosis (1). According to a 2021 clinical review of psychiatric sequalae of hyperparathyroidism, catatonia has only been reported in the literature in one case (2). We present a case of acute catatonia in a patient with hypercalcemia due to primary hyperparathyroidism and a subsequent literature review.

Case: Ms. V, a 73-year-old woman with no prior psychiatric history and a medical history of primary hyperparathyroidism secondary to parathyroid adenoma was admitted due to hypercalcemia. She underwent parathyroidectomy, and two days after surgery (hospital day 10 )she developed acute mental status changes which prompted psychiatric consultation. On evaluation, she showed signs of catatonia including automatic obedience, echopraxia, echolalia, perseveration, verbigeration, ambitendency, mitgehen, and waxy flexibility; Bush-Francis Catatonia Rating Scale (BFCRS) was 22. Intravenous lorazepam was started with an initial dose of 2mg, followed by 1mg every 8 hours. On hospital day 11, her BFCRS score decreased to 5, and lorazepam was discontinued. On hospital day 12, her BFCRS score was 0. Over this time-frame, her calcium normalized from 11.2mg/dL at the onset of catatonia symptoms, to 8.4mg/dL at their resolution. The rapid symptomatic improvement as calcium normalized without recurrence of catatonic symptoms with benzodiazepine discontinuation suggests that hypercalcemia was the most likely cause of her catatonia.

Methods: We conducted a review of available literature on catatonia in patients with hypercalcemia and/or hyperparathyroidism. PubMed, Medline, and PsycInfo were searched by authors. The following searches were performed: “catatonia AND (hypercalcemia OR hyperparathyroidism)”; “catatonia AND hypercalcemia AND hyperparathyroidism”.

Results: The searches yielded 10 articles. Five articles met our inclusion criteria of being in English, accessible, and pertaining to specific patients who exhibited neuropsychiatric symptoms with known hypercalcemia and/or hyperparathyroidism. Two of these articles described cases consistent of catatonia with one article showing a clear resolution of symptoms in relation to normalizing serum calcium.

Discussion: To our knowledge, this is only the second reported case of acute catatonia that resolved with correction of hypercalcemia. We present results from our literature review, differential diagnoses, and management strategies of hypercalcemia and hyperparathyroidism in this clinical context. The mechanism by which hyperparathyroidism and hypercalcemia lead to neuropsychiatric symptoms are unclear and theories will be discussed.

Implications: Hypercalcemia and hyperparathyroidism should be considered when evaluating for potential causes of catatonia, and their correction may alleviate catatonic symptoms.

Sources:

< !1. Nagy L, Mangini P, Schroen C, Aziz R, Tobia A. Prolonged Hypercalcemia-Induced Psychosis. Case Rep Psychiatry. 2020 Feb 1;2020:6954036.

< !2. Serdenes R, Lewis M, Chandrasekhara S. A Clinical Review of the Psychiatric Sequelae of Primary Hyperparathyroidism. Cureus. 2021 Oct 27;13(10).