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We report a case of dramatic reversal of ca tato nic sym pto ms with a sing le dose of midazolam, an ultra short ac t ing parenteral benzodiazepine com monly used for procedure sedation. Mr. S. is a 50 yea r old Cauca sian male ad mit te d to th e Kan sas C ity VA Medica l C enter with a six week history of depressive sym ptoms culm ina t ing in a suicide attempt. He was initially placed on nortriptylin e 75 mg PO daily with som e im provement noted. Upon retu rn from a pa ss on e week aft er ad mission th e patien t appeared confused and disorient ed. A urine drug scr een was negative and CT sca n wit hout contrast was normal on th e following morning. Over th e next severa l days th e pa tien t became incr easingly agita te d a nd disoriented , refusin g all food a nd fluid s, roa ming a im lessly around his room, and sp eaking in a totally incoh erent manner. T he pat ient a lso com plaine d of intermittent ge ne ralized abdom ina l pain witho u t evide nce of vomiting or diarrhea . Except for his altered mental sta tus , his ph ysical a nd neurological exa ms were within normal limits. Because of incr eased agi ta tio n a nd confusion, four-point restraints and IV fluid s were initiat ed . Except for eleva t ion of WBC to 16,000, initial laboratory evalua t ion including elect ro lytes, glucose, BUN, creatine, SC O T, SC PT , blood ammonia , a Schwartz-Watson test , abdomina l xrays a nd CS F exa m was normal. Because of con tinued altered ment al s ta t us, a second CT sca n wit h con t rast was performed three days lat er , at whi ch ti me midazo lam 2 mg and mep eridin e 50 mg were given 1M for sedat ion. Hi s symptoms of confus ion and di sori entation com ple tely cleared within 20 minutes of med ica t ion ad m inist ra tio n. H e remained cohe re n t a nd orien te d ove r th e nex t three hours, a nd lorazepa m 2 mg PO every four hours was started . C areful review of his past medica l records reveal ed a simila r episode of disori entation following a maj or depressive episode four years pri or to th e cur re n t ad m ission. Based upon clinical hist ory, presenting symptom s, lab a nd pharmacological findings, th e di agn osis of bip olar di sorder wit h ca ta to nia was mad e. H e was placed on lithium 600 mg PO BID a nd loraz ep am was con tinue d a t a dos e of 2 mg PO Q ID for seventeen days unt il clon azep am 0.5 mg PO Q ID was started for tapering purposes . During th e taperi ng process, he expe rience d a bri ef recurren ce of confusion a nd d isorientat ion wh ich was readily reversed by slowin g the rat e of clonazepam tap er. Clonaz epam taper was com pleted ten days after dis cha rge from th e hospital. He has remained sym ptom fr ee during a nin e (9) month period of follow-up. In recent years , benzodiazepines have been used with increasin g freq uency for reversal of ca ta tonia. Possibl e ph armacologic mech anism s of this ac tion have been proposed based upon clinical observations a nd data ga the red from a nima l expe rimentation ( I). Previously described use of 510 mg midazolam 1M/IV in a patient with

Reversal of Catatonia with Midazolam