Recurrent Catatonia in the Setting of Urinary Tract Infection and Medical Comorbidity: A Case Report

Catatonia is a neuropsychiatric syndrome characterized by disturbances in motor activity, affect, and autonomic function. Although often associated with primary mood or psychotic disorders, it can be precipitated or sustained by systemic infections such as urinary tract infection (UTI). We describe a 60-year-old man with recurrent catatonia and diagnoses of schizophrenia, bipolar disorder, and major neurocognitive disorder, whose latest episode of catatonia, described in this case report, was preceded by psychosocial stress and appeared to be exacerbated by polymicrobial UTI, bacteremia, and urosepsis. He had a history of neuroleptic malignant syndrome (NMS) and an inconsistent response to electroconvulsive therapy (ECT), limiting usual first-line treatment options. During this admission, he developed Klebsiella pneumoniae UTI with Staphylococcus simulans bacteremia and later Pseudomonas aeruginosa urosepsis, in the context of mixed central and nephrogenic diabetes insipidus likely related to long-term lithium therapy. The patient's catatonia proved refractory to very high-dose lorazepam but improved with an intensive, multimodal regimen including intravenous (IV) benzodiazepines (diazepam, midazolam), enteral and subsequently oral lorazepam, zolpidem, memantine, and aggressive treatment of infection and electrolyte abnormalities. He ultimately regained baseline function and was discharged on a slow taper of benzodiazepines and zolpidem. This case illustrates the bidirectional relationship between infection, autonomic and immune dysregulation, and catatonia; highlights practical challenges when treatment with benzodiazepines and ECT is constrained by medical comorbidity; and supports considering adjunctive GABAergic and glutamatergic agents in carefully selected cases of refractory catatonia, under close specialist supervision.