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Background: The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health threats of our generation. A significant portion of patients are presenting with delirium and neuropsychiatric sequelae of the disease. Unique examination findings and responses to treatment have been identified., Objective: In this article, we seek to provide pharmacologic and treatment recommendations specific to delirium in patients with COVID-19., Methods: We performed a literature search reviewing the neuropsychiatric complications and treatments in prior coronavirus epidemics including Middle Eastern respiratory syndrome and severe acute respiratory syndrome coronaviruses, as well as the emerging literature regarding COVID-19. We also convened a work group of consultation-liaison psychiatrists actively managing patients with COVID-19 in our hospital. Finally, we synthesized these findings to provide preliminary pharmacologic recommendations for treating delirium in these patients., Results: Delirium is frequently found in patients who test positive for COVID-19, even in the absence of respiratory symptoms. There appears to be a higher rate of agitation, myoclonus, abulia, and alogia. No data are currently available on the treatment of delirium in patients with COVID-19. Extrapolating from general delirium treatment, Middle Eastern respiratory syndrome/severe acute respiratory syndrome case reports, and our experience, preliminary recommendations for pharmacologic management have been assembled., Conclusions: COVID-19 is associated with neuropsychiatric symptoms. Low-potency neuroleptics and alpha-2 adrenergic agents may be especially useful in this setting. Further research into the pathophysiology of COVID-19 will be key in developing more targeted treatment guidelines., (Copyright © 2020 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Pediatric catatonia is believed to be a rare condition, but challenges in recognition and variability in presentation may lead to underdiagnosis. Early identification and effective treatment of pediatric catatonia is critical given the significant morbidity and mortality associated with the condition. Given the widespread shortage of child and adolescent psychiatrists, at times consultation-liaison (C-L) psychiatrists without child training may be the frontline specialty providers asked to guide treatment of these pediatric patients., Objective: To review the literature on pediatric catatonia using clinical cases to illustrate unique aspects of its presentation, evaluation, and management., Methods: We describe the presentation and management of 6 adolescents with catatonia on an inpatient pediatric service at a general hospital and use these cases as a focal point for a review of the literature., Conclusion: Pediatric catatonia is a potentially lethal disease entity that can be effectively treated if accurately identified early in its course. Psychiatrists working in a C-L setting may encounter this syndrome and should be aware of its presentation, evaluation, and management., (Copyright © 2018. Published by Elsevier Inc.)

Background: Neurologic deterioration occurring days to weeks after a cerebral hypoxic event accompanied by diffuse white matter demyelination is called delayed posthypoxic leukoencephalopathy (DPHL). Manifestations of DPHL are diverse and include dementia, gait disturbance, incontinence, pyramidal tract signs, parkinsonism, chorea, mood and thought disorders, akinetic mutism, and rarely catatonia., Methods: We report a case of malignant catatonia in a patient diagnosed with DPHL that was refractory to electroconvulsive therapy (ECT) and review the literature on catatonia in DPHL., Results: The patient was a 56-year-old woman with schizoaffective disorder who was admitted with catatonia 2 weeks after hospitalization for drug overdose and respiratory failure. Her catatonic symptoms did not respond to treatment of lorazepam, amantadine, methylphenidate, or 10 sessions of bilateral ECT at maximum energy. Repeat magnetic resonance imaging revealed extensive periventricular white matter lesions not present on admission scans, and she was diagnosed with DPHL., Discussion: No treatment for DPHL has been proven to be widely effective. Hyperbaric oxygen treatments may reduce the rate of development, and symptom improvement has been reported with stimulants and other psychotropic agents. Review of literature reveals rare success with GABAergic agents for catatonia after cerebral hypoxia and no cases successfully treated with ECT. There are 7 case reports of neurologic decompensation during ECT treatment after a cerebral hypoxic event., Conclusion: Caution is advised when considering ECT for catatonia when delayed sequelae of cerebral hypoxia are on the differential diagnosis, as there is a dearth of evidence to support this treatment approach., (Copyright © 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Neuroleptic malignant syndrome (NMS) represents an iatrogenic form of malignant catatonia, and simple catatonia has been shown to predispose to NMS., Objective: The authors present the case of a bipolar patient with catatonic features who developed NMS after receiving haloperidol., Method: Supportive therapy, including rehydration, electrolyte restoration, and blood pressure aids were given, together with antipyretics, antibiotics, and anticoagulants. The patient was also started on bromocriptine and diazepam., Results: Supportive care, diazepam, and dopamine agonists yielded only partial benefit. However, switching from diazepam to lorazepam, in combination with electroconvulsive therapy (ECT) and a long-acting dopamine agonist led to the resolution of NMS., Conclusion: This case sheds further light on the relationship between catatonia and NMS. As noted in the literature, ECT in combination with lorazepam proved to be safe and effective for NMS.

Background: Bell's mania (mania with delirium) is an acute neurobehavioral syndrome of unknown etiology that is characterized by the rapid onset of grandiosity, psychomotor excitement, emotional lability, psychosis, and sleep disruption consistent with mania, coupled with alterations in sensorium, and disorientation characteristic of delirium. Catatonia is a common feature of the syndrome., Method: The authors describe a case of recurrent delirium/mania with prominent catatonic features after a cerebellar and pontine stroke, and subsequent successful treatment with lorazepam., Results: Symptoms quickly resolved after antipsychotics were discontinued, with continuation of valproate and lorazepam treatment., Discussion: Failure to recognize this patient's syndrome as a form of catatonia could have had severe, even life-threatening, consequences. The use of neuroleptic medications in cases of delirium/mania with catatonic signs may result in marked clinical deterioration, whereas high-dose lorazepam can ameliorate catatonic signs.