Catatonic signs during delirium in leptomeningeal melanoma: Treatment trade-offs in end-of-life care.
Luis Velez Figueroa
✦ AI-curated · Sources linked
Case in brief
A man in his late 30s with metastatic melanoma involving the leptomeninges and brain developed fluctuating arousal, inattention, disorientation, mutism, immobility, staring, withdrawal, and waxy flexibility. His BFCRS score fell from 7 to 1 after intravenous lorazepam, but sedation and variable wakefulness limited reassessment, and transient gains in movement and speech did not improve attention, communication, intake, mobility, or function sustainably. Lorazepam was reduced and stopped when severe agitation emerged. Scheduled haloperidol was then associated with improved evening agitation without documented extrapyramidal symptoms, oversedation, or QTc prolongation. A supervised oral-medication trial supported discharge planning, though insurance barriers delayed hospice placement.
What made this case unusual
The case illustrates the diagnostic and treatment difficulty of catatonic signs occurring alongside delirium in advanced leptomeningeal melanoma: a lower BFCRS score after lorazepam did not correspond to sustained functional improvement, while sedation complicated assessment.
Diagnostic / clinical pearl
Interpret a change in BFCRS in context: assess wakefulness, attention, communication, mobility, and function, since a lower score after lorazepam may not represent meaningful clinical improvement when sedation and delirium persist.
Why it matters
In end-of-life care, medication choices may need repeated adjustment as priorities shift among interaction, safety, and comfort, with decisions informed by prognosis and the feasibility of care at home.