Objective: To report a patient with malignant catatonia from abrupt clozapine discontinuation.

Background: Clozapine blocks 5HT_2A/5HT_2C serotonin and dopamine receptors. Cholinergic and serotoninergic rebounds have been reported in clozapine withdrawal, but catatonia is rare.

Method: Case report

Results: A 53-year-old woman with history of schizophrenia since age 20, on clozapine 200 mg/day and sertraline 50 mg/day, and diabetes presented with behavioral change and abnormal movements. Three days before the admission, she did not eat, sleep and speak with others. She talked to herself, and poured water on her head. She developed generalized chorea involving bilateral arms, legs and trunk, more on the right, for one day. On admission, she had blood sugar was 274 mg/dL and ketoacidosis. Serum creatine kinase (CK) was 1,610 U/L. She was diagnosed with chorea associated with euglycemic diabetic ketoacidosis, and treated with intravenous insulin and two doses of intramuscular haloperidol. Due to the initial concern of “neuroleptic malignant syndrome (NMS)”, clozapine and sertraline were held by the psychiatrist. She developed fever which improved within a few days of antibiotics, but no clear source of infection was found. Once blood sugar and ketoacidosis are under control, the patient still had paucity of general movements and unresponsiveness. Examination showed mutism, stupor, negativism, waxy flexibility and posturing, compatible with catatonia. There was no myoclonus, tremor or hyperreflexia. She was treated with intravenous fluid and cyproheptadine 16 mg/day without improvement. Clozapine was resumed at low dose, and titrated up slowly, along with lorazepam 1 mg three times a day. Serum CK decreased to 521 U/L. Her consciousness and movements improved dramatically 6 days later, while on clozapine 75 mg/day. She became more alert, able to speak, follow commands, and had more spontaneous movements. Clozapine was slowly increased to 225 mg/day, and sertraline was added. Her consciousness and spontaneity of movements gradually returned to baseline, and she was discharged home.

Conclusion: It is important to recognize malignant catatonia secondary clozapine withdrawal. Misdiagnosis of this movement disorder emergency as others such as NMS can lead to prolonged clozapine holding and potentially fatal outcomes. Abrupt discontinuation of clozapine should be avoided, and slow tapering is recommended.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/malignant-catatonia-secondary-to-clozapine-withdrawal-a-case-report/