Assistant Program Director Corewell Taylor Taylor, Michigan, United States
Case Diagnosis: Critical Illness Myopathy in acutely Catatonic ICU patient
Case Description: 36 year old male with schizophrenia was admitted with catatonia and difficulty swallowing. He developed aspiration pneumonia and decompensated, requiring intubation; he was extubated after 3 days. He was found to have significant weakness in all 4 extremities. AIDP workup was negative. 1 week following extubation, he decompensated, requiring reintubation for a further 3 days. EMG was performed in the ICU to differentiate ongoing catatonia from neuromuscular cause of weakness such as neuromuscular disorders vs critical illness myopathy or polyneuropathy. Electrodiagnostic testing was performed of bilateral lower and left upper extremity. Needle exam was complicated due to low patient participation and intolerance of pain. NCSof bilateral lower and left upper extremity were within normal however needle EMG showed acute denervations in the proximal left upper extremity muscles with small polyphasic motor units. Electrodiagnostic evidence was consistent with Critical Illness Myopathy.
Discussions: Catatonia occurs in 20-30% of schizophrenia patients and its pathophysiology is poorly understood. Catatonia presents with abnormal movement patterns including waxy flexibility, gegenhalten and mitgehen, stereotyped movements, or stuporous catalepsy with very little response to outside stimuli. Catatonia must be differentiated from other movement disorders, including neuroleptic malignant syndrome, serotonin syndrome, or extrapyramidal effects of neuroleptics. In our case, the profound muscle weakness led to aspiration pneumonia due to poor effort of swallow, leading to 6 days on vent and an extended ICU stay of 15 days.
Conclusions: Inpatient EMG has utility in differentiating organic from psychogenic causes of movement disorder. Confirmation of critical illness myopathy using electrodiagnostics is important to help differentiate psychiatric disorders from CIM or CIP. Ultimately, using electrodiagnostics in the acute care setting can help assess rehabilitation needs, predict prognosis and assist with medical management.
