Delayed and Unusual Presentation of Catatonia Secondary to Synthetic Cannabinoid Ingestion

Synthetic Cannabinoids (SCs) have been linked to several cases of catatonia in patients without a pre-existing affective or psychotic disorder. This patient is an adolescent male with no past psychiatric medical history who presented with altered mental status and odd behavior after ingesting SC. After admission, the patient started to display waxing and waning mental status, profound somnolence, with intermittently minimally verbal output as well as paranoia/suspiciousness. His mental status continued to worsen despite negative infectious and neurologic workups. Initially, he received lorazepam 2mg IV on multiple occasions but was documented to fall sleep immediately after. On Day 9, he was started on low dose risperidone due to bizarre behaviors and development of increased paranoia. After receiving two doses of risperidone, he developed worsening slowed speech, staring, and psychomotor retardation, at which point risperidone was stopped and lorazepam 1mg IV TID was started. In the next two days, lorazepam was titrated up to 2.5 mg TID, at which point he experienced significant improvement in mental status, movement fluidity, and verbal output. He was discharged on this regimen on Day 12 with near pre-illness level of functioning. Notably, he remained hypertensive throughout his hospital course, even after catatonic symptoms improved, and was discharged on amlodipine 5mg. This case illustrates an atypical presentation of catatonia secondary to SC ingestion, with catatonia developing multiple days after ingestion and pre-empted by waxing and waning mental status. Additionally, although initial lorazepam challenges were equivocal, this patient responded positively to a more prolonged, scheduled trial.