Treatment of hepatitis C with interferon-alpha and ribavirine in a patient with long-term clozapine treatment.

TO THE EDITOR: The interesting report of catatonia presentation with bradycardia by Freudenreich et al. splendidly highlights the importance of identification of catatonic symptoms in clinical practice. However, there are a few issues that need to be highlighted, particularly from the point of view of a psychiatrist presented with a patient with catatonic symptoms. The first relates to the likelihood of this presentation being a form of epilepsy. The authors themselves briefly consider this possibility. In the patient described, there is a previous history of (unspecified) head injury, bradycardia (40 bpm), Glasgow Coma Scale score of 3, administration of antipsychotics, and a history of a similar episode in the past. As the authors describe, an EEG examination was not felt to be clinically indicated in this case. We would wish to emphasize further, however, the importance generally of the possibility of epilepsy in presentations of catatonia with bradycardia. Almansori et al. report a case of asymptomatic ictal bradycardia diagnosed during video EEG telemetry, and they stress that partial seizures (of temporal origin) can be associated with clinically significant tachycardia or bradycardia. Importantly, ictal bradycardia and asystole has been implicated as one of the causes of Sudden Unexpected Death in Epileptic Patients (SUDEP). Another study has indicated that ictal bradycardia can be explained by influence of the central autonomic network of the insular cortex and temporal lobe, and there appears to be a plethora of reports on ictal bradycardia, mostly with temporal lobe seizures. Not only can catatonic features occur in epilepsy, but a positive response to benzodiazepines can be seen in both epilepsy and catatonia. Suzuki et al. report on three patients in whom catatonic stupor persisted after resolution of the epileptic seizures. They emphasize the importance of EEG examination in patients with catatonic stupor, for early recognition of nonconvulsive status epilepticus, as well as epileptic seizures superimposed on catatonic stupor. The report also highlights the information that ECT is helpful for persistent catatonic stupor after resolution of seizures. Although it is important to consider the possibility of catatonic symptoms in patients presenting with stupor, the presence of unusual episodic symptomatology with bradycardia should trigger investigations to rule out epilepsy. Catatonic symptoms can, and do, present with other general-medical conditions, including epilepsy. The second issue relates to the possibility of bradycardia being secondary to antipsychotic medication (olanzapine as well as haloperidol). In the absence of ECG data, it is not possible to comment on whether the bradycardia reflected a prolonged QTc. A prolonged QTc, as well as bradycardia, could be likely precursors of torsades de pointes, which could well be fatal. Although, this does not explain the appearance of catatonic symptoms, it is possibly important to state that any bradycardia of 40 bpm needs to be investigated, and an ECG examination would be helpful. We argue that although it is very important to look for catatonic symptoms, it is probably no less important to rule out other, cardiac, causes of bradycardia as well as the possibility of a seizure phenomenon. Niraj Ahuja, M.D., MRCPsych Wallsend Community Mental Health Team, Wallsend, U.K. and School of Neurology, Neurobiology, and Psychiatry University of Newcastle-uponTyne, U.K. Adrian J. Lloyd, MRCPsych, M.D. Wallsend Community Mental Health Team, Wallsend, U.K. and School of Neurology, Neurobiology, and Psychiatry University of Newcastle-uponTyne, U.K.