Exploring the questions that connect clinical understanding with human experience.

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“Clinical Reasoning in Refractory Catatonia With Elevated Anti–Thyroid Peroxidase Antibodies", to Journal of General Internal Medicine


Abstract

This clinical reasoning case report describes an adult patient without prior psychiatric history who developed acute behavioral and cognitive changes progressing to mutism, rigidity, stereotyped movements, poor oral intake, and functional decline. Catatonia is a neuropsychiatric syndrome associated with psychiatric, neurologic, and medical conditions, and refractory or atypical presentations warrant evaluation for secondary causes. Extensive infectious, metabolic, structural, epileptic, autoimmune, and paraneoplastic evaluations were unrevealing. Thyroid function remained normal; however, anti–thyroid peroxidase antibodies were elevated. Catatonic symptoms persisted despite high-dose benzodiazepine therapy, prompting electroconvulsive therapy (ECT). Given the refractory course and concern for a possible autoimmune contribution, adjunctive intravenous corticosteroids were administered. The patient subsequently demonstrated marked improvement in catatonic symptoms following combined ECT and corticosteroid treatment, although residual cognitive deficits persisted. This case highlights the importance of systematically evaluating secondary causes of refractory catatonia and cautiously interpreting thyroid autoantibodies within the broader clinical context. Although treatment response cannot establish causality, adjunctive immunotherapy may warrant consideration in carefully selected patients after alternative etiologies have been excluded.

Keywords: catatonia; autoimmune encephalopathy; anti-thyroid peroxidase antibodies; electroconvulsive therapy; corticosteroids

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Patient Perspective of Quality of Life During Home Parenteral Nutrition and Post-Transplant in Children and Adult

2023 · University of Illinois College of Medicine

Patient-perspective presentation exploring quality-of-life considerations across home parenteral nutrition, pediatric post-transplant care, transition to adult care and long-term adult transplant care.

  • Patient Perspective of Quality of Life During Home Parenteral Nutrition and Post-Transplant in Children and Adults

    Alana N. Carr, MS
    University of Illinois College of Medicine, Chicago, Illinois

    Background: Advances in intestinal and multivisceral transplantation have allowed recipients to survive well beyond the immediate postoperative period, making long-term quality of life (QOL) an important component of transplant care. Traditional problem-based care may inadequately capture patient priorities because biomedical measures of disease severity do not necessarily correlate with patients' perceptions of QOL. Goal-directed health care provides an alternative framework that incorporates patient-defined goals into clinical decision-making. 

    Objective: To describe QOL considerations across home parenteral nutrition, pediatric post-transplant care, transition to adult care, and long-term adult post-transplant care from the perspective of a long-term multivisceral transplant recipient.

    Approach: This patient-perspective presentation integrates lived experience following liver, small-bowel, and pancreas transplantation with established QOL concepts. QOL was considered across four interconnected domains: environment, independence, physical functioning and symptom management, and psychological/social well-being. Particular attention was given to nutrition, chronic symptom management, developmental milestones, healthcare maintenance, and continuity of care across the lifespan.

    Key Observations: QOL priorities evolve as transplant recipients move from childhood into adulthood. Pediatric concerns include participation in school, play and hobbies; travel and sleepovers; pain, hygiene and physical functioning; and social inclusion and understanding of one's condition. Transition to adult care introduces additional challenges involving insurance coverage, access to appropriately specialized clinicians, care coordination, confidence in self-management, and adjustment to new providers. In adulthood, QOL considerations expand to college, employment, finances, activities of daily living, travel, medication and symptom management, prognosis, advance care planning, family goals, and the cumulative burden of lifelong healthcare maintenance. 

    Conclusion: Long-term transplant success should encompass more than graft survival and biomedical stability. Patient-centered transplant care should routinely consider how treatment affects independence, physical functioning, social participation, psychological well-being, and the patient's ability to pursue meaningful life goals. Incorporating patient-defined QOL goals throughout nutritional support, pediatric care, transition, and adulthood may provide a more comprehensive framework for lifelong transplant care. 

    Keywords: quality of life; intestinal transplantation; multivisceral transplantation; home parenteral nutrition; patient-centered care; transition of care; survivorship