Catatonia was the label. Delayed post-hypoxic leukoencephalopathy was the diagnosis.

The initial crisis

A 50-year-old woman was found unresponsive in her home for an unknown amount of time. When she was brought to the hospital, she was febrile with a temperature of 40.22°C. She had a medical history of anxiety and depression, for which she took escitalopram, buspirone, and quetiapine.

Early tests showed a body in metabolic failure. She was in renal failure and had rhabdomyolysis with an elevated creatinine phosphokinase. Her liver function tests were severely elevated, leading to a diagnosis of shock liver, and she had acute pancreatitis. In the intensive care unit, she required dialysis. During this initial workup, a CT scan and an MRI of her brain were both normal.

A brief recovery

By the third day of hospitalization, the woman's renal function began to stabilize and she no longer required dialysis. Her mental status improved, returning to her normal baseline. On day six, she was stable enough to be transferred out of the ICU. It appeared she had survived the acute insult.

The neurobehavioral decline

On day 19, her mental state acutely deteriorated. She became mute and fell into a stupor, staring and unable to follow commands. She stopped eating. When she developed cogwheel rigidity in her right wrist, doctors suspected catatonia secondary to her history of major depression.

Psychiatry and neurology were consulted. Following the suspicion of psychiatric catatonia, her antidepressant and anti-anxiety medications were held, and she was started on lorazepam. The dose was titrated upward over six days, but her condition did not improve.

The actual diagnosis

The lack of response to lorazepam caused her medical team to doubt the psychiatric label. They ordered a repeat MRI of the brain. Unlike the normal scan from her admission, this new imaging revealed diffuse white matter changes across the frontal, temporal, parietal, and occipital lobes of both hemispheres.

The diagnosis was shifted to delayed posthypoxic leukoencephalopathy (DPHL), a rare syndrome where cerebral demyelination occurs days or weeks after a hypoxic event. The "lucid interval" she experienced—recovering her cognition before the crash—is a hallmark of the condition, thought to be related to the half-life of myelin-related proteins.

Treatment and outcome luxury

Once the medical cause was identified, her treatment plan changed. She was started on carbidopa/levodopa 25/100 mg for encephalopathy. Following this change, the patient’s condition improved significantly. She was ultimately discharged to a rehabilitation facility with scheduled follow-ups in neurology and nephrology.