Elsevier

Biological Psychiatry

Volume 44, Issue 6, 15 September 1998, Pages 499-507
Biological Psychiatry

Original Articles
Serum iron in catatonia and neuroleptic malignant syndrome

https://doi.org/10.1016/S0006-3223(98)00109-7Get rights and content

Abstract

Background: Preliminary data suggest that decreased serum iron levels predict the progression of catatonia to neuroleptic malignant syndrome (NMS). This study examines the predictive value of low serum iron in this NMS conversion and explores other potential significance of serum iron in catatonia.

Methods: Fifty patients with catatonia were prospectively identified at two psychiatric intensive care units during a 3-year period [incidence of 5% (39/716) and 13% (11/86) respectively]. Serum iron was measured in 39 episodes. Seventeen episodes (44%) showed low serum iron levels. A retrospective chart review of patients identified was conducted, comparing those with low and normal serum iron levels.

Results: Low serum iron levels were associated with malignant catatonia, excited catatonia, and poor responses to benzodiazepines. There were 7 episodes of malignant catatonia. All had low serum iron. Neuroleptics were used in 5 of them, and all 5 evolved into NMS. No such NMS conversion was noted in those with normal serum iron or in nonmalignant catatonia with low serum iron. Seven episodes (with low serum iron) failing benzodiazepine therapy responded subsequently to lithium–neuroleptic combination therapy.

Conclusions: Malignant catatonia, associated with low serum iron, is at high risk of evolving into NMS. Low serum iron in nonmalignant catatonia does not predict this NMS conversion. Excited catatonia as a catatonic subtype (associated with low serum iron and unfavorable benzodiazepine responses) deserves more research attention. There appears to be a possible connection between treatment resistance to benzodiazepines, favorable responses to lithium–neuroleptic combination, and low serum iron.

Introduction

The finding of decreased serum iron levels in neuroleptic malignant syndrome (NMS) (Rosebush and Mazurek 1991) has evoked discussion over its diagnostic significance and the putative role of iron modulatory effects on dopamine receptors in the pathogenesis of NMS White and Brown 1990, Weller and Kornhuber 1993. In support of the hypothesis that NMS is a severe variant of catatonia Fink 1995, Carroll and Goforth 1995 reported a similar decrease of serum iron in three of 12 catatonic episodes. NMS eventually developed in two of the three episodes, while the third one without exposure to neuroleptics did not progress to NMS. Serum iron was not remeasured after the catatonic episodes resolved. The authors suggested that decreased serum iron levels in catatonia predict those who will evolve into NMS, but cautioned the need for confirmatory studies with larger sample sizes and postresolution serum iron levels.

This study replicates the finding of reduced serum iron levels in acute catatonia in a larger sample, and it intends to examine the predictive value of low serum iron in the progression of catatonia to NMS and explore other potential diagnostic and therapeutic significance of serum iron in catatonia.

Section snippets

Methods and materials

During a 3-year period, 50 patients with catatonia were seen in two psychiatric intensive care units at Tokanui Hospital, New Zealand (23-bed Intensive Psychiatric Care Unit, 39 patients) from June 1993 to October 1995 and at Graylands Hospital, Western Australia (five-bed Acute Care Unit, 11 patients) from December 1995 to July 1996. All patients admitted to the two psychiatric hospital locked facilities during the specified periods were under the care of the author or the care of psychiatric

Results

Of 716 patients (506 male, 210 female of 1257 admissions) admitted to the Tokanui Hospital unit during the 28-month period, 39 patients [20 male, 19 female, aged 16–73, mean age 33.5 years (SD = 14.3); Patients 1–39] had one or more catatonic episode. This represented 5% of the patient population. As not all admissions were screened for catatonia, milder cases would have been missed. Eleven [7 male, 4 female, aged 23–59, mean age 36.1 years (SD = 10); Patients 40–50] of 86 patients (42 male, 44

Discussion

Catatonia is a behavioral neurological syndrome of diverse etiology (Taylor 1990), generally regarded as having two states—retardation (stupor) and excitement (Morrison 1973). Lethal catatonia, a life-threatening condition first described in the preneuroleptic era (Stauder 1934), is characterized by relentless catatonic excitement, delirium, hyperpyrexia, and autonomic dysfunction leading to stuporous exhaustion. Less frequently the disorder follows primarily a stuporous course (Mann et al 1986)

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