CASE REPORT Year : 2022  |  Volume : 59  |  Issue : 2  |  Page : 273-275  

Cotard's syndrome in the postoperative period following head and neck cancer surgery – A case report

Nitish Thakur1, Mahima Gupta2, Raghav Gupta1, Seema Mishra1
1 Department of Onco-Anaesthesiology and Palliative Medicine, AIIMS, Ansari Nagar, New Delhi, India
2 Department of Anaesthesiology, Pain and Critical Care, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India

Date of Submission24-Jul-2020Date of Decision12-Aug-2020Date of Acceptance10-Jan-2021Date of Web Publication29-Jun-2022

Correspondence Address:
Seema Mishra
Department of Onco-Anaesthesiology and Palliative Medicine, AIIMS, Ansari Nagar, New Delhi
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijc.IJC_825_20

Major head and neck surgery is a known factor for postoperative delirium; however, Cotard's syndrome (CS) has been rarely reported following head and neck surgery. We report a case of a 51-year-old man who underwent surgery for carcinoma right buccal mucosa and developed agitation and nihilistic delusion after extubation. The patient had a preexisting psychiatric history which is often reported as a risk factor for CS. Of interest, though is that this condition subsided as quickly as it emerged with only supportive counselling and brief pharmacotherapy.

Keywords: Delirium, electroconvulsive therapy, surgery, syndrome

How to cite this article:
Thakur N, Gupta M, Gupta R, Mishra S. Cotard's syndrome in the postoperative period following head and neck cancer surgery – A case report. Indian J Cancer 2022;59:273-5
How to cite this URL:
Thakur N, Gupta M, Gupta R, Mishra S. Cotard's syndrome in the postoperative period following head and neck cancer surgery – A case report. Indian J Cancer [serial online] 2022 [cited 2022 Aug 9];59:273-5. Available from: https://www.indianjcancer.com/text.asp?2022/59/2/273/348464   Introduction 

Cotard's syndrome (CS) was first described by Jules Cotard in 1880 and it comprises of a number of delusions that range from having fixed belief of having lost internal organs, soul, or being dead or putrefying.[1] The nosographic characterization of this syndrome remains elusive, and it is not classified as a separate disorder in either International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[2],[3] CS may be associated with some specific conditions of perceived isolation, such as hospital admissions and surgical interventions and is a rare neuropsychiatric condition that can emerge independently during the course of other psychiatric or neurological diagnoses.[4],[5] We report the case of a middle-aged male who developed symptom characteristics of CS in the postoperative period following head and neck cancer surgery.

  Case Report 

A 51-year-old male patient presented to the preanesthetic check-up (PAC) clinic of the Department of Onco-Anesthesia and Palliative Medicine at All India Institute of Medical Sciences, New Delhi, with the diagnosis of carcinoma head and neck stage – T3N2M0 right buccal mucosa and was scheduled for elective surgery. His baseline laboratory investigations were within normal range and PAC was unremarkable except for an anticipated difficult airway (mouth opening of less than 1 cm). In view of this finding, nasal fiber-optic intubation was planned for which he gave his informed consent.

On the day of surgery, the patient was premedicated with intravenous (IV) glycopyrrolate 0.2 mg and his airway was nebulized with 4% lignocaine (5 mL). A 20 G IV line was placed in his left upper limb with standard American Society of Anesthesiologists monitoring (i.e., ECG, SPO2, NIBP) in place. Xylometazoline (0.2%) nasal drops were administered in both nostrils (two drops per nostril) for mucosal vasoconstriction. As the patient was anxious, he was given IV midazolam 1 mg with IV Fentanyl 20 mcg, titrated to a modified Ramsey Sedation scale of two.[6] Fiberoptic-guided nasotracheal intubation was performed and endotracheal placement confirmed with fiberoptic visualization and capnography. General anesthesia was induced with fentanyl 1 mcg/kg, propofol 1.5–2 mg/kg, and rocuronium 0.6 mg/kg, while maintenance was done with oxygen–air mixture (50:50) and sevoflurane (Minimum alveolar concentration – 0.7), fentanyl 1 mcg/kg/hour and rocuronium 0.1 mg/kg to achieve a bispectral index of 40–60. Surgery included major resection of the floor of mouth followed by elective tracheostomy, performed by an oncosurgeon who was present on standby.

The patient's intraoperative course was uneventful, and he was shifted to ICU for elective ventilation. He received ongoing analgesia in the form of patient-controlled fentanyl at a baseline infusion rate of 0.5 mcg/kg, while sedation was maintained with midazolam 1 mg/hour titrated to a modified Ramsey sedation score of four.[6] Sedation was ceased 12 hour following the surgery, and ventilatory support was weaned off when he became fully awake.

He was shifted to the general surgical ward, but within 4 hour, he became agitated and tried to remove the surgical drains and nasogastric tube. Initially, his condition was diagnosed as postoperative delirium, even though, his vitals were normal with no sign of dehydration and his blood investigations had ruled out any possibility of hypoglycaemia, hypoxemia, and dyselectrolytemia.

Since the patient was agitated, he was given an injection of haloperidol 1 mg to manage the symptoms. Efforts at oral communication were limited because of the tracheostomy; however, he was able to write down – “I was conscious while the tube was inserted but died during the surgery.” He added “My skin and organs were removed from my body, and replaced with plastic. I have been revived with the help of ventilator and other machines.” He refused to take medications and thus a psychiatry referral was requested. Psychiatry advised us to continue additional doses of IV haloperidol up to a maximum dose of 4.5 mg/day with ECG monitoring for any QTc changes.[7]

The patient's son later revealed that around 11 months ago his elder brother had passed away in a road accident. While the patient was still grieving the loss of his elder son, he also received his diagnosis of cancer leaving him feeling overwhelmed with emergence of insomnia and anxiety for which he was advised benzodiazepines prior to surgery.

Patient's nihilistic thinking improved within 7 days of pharmacological intervention, and he was discharged with advice to take oral haloperidol 0.5 mg daily and to attend Psychiatry and Surgical Oncology outpatient clinics. A telephonic follow-up interview done after 1 month revealed that he was feeling much better and had stopped haloperidol after 2 weeks.

  Discussion 

CS is a rare neuropsychiatric condition that can emerge independently during the course of other psychiatric or neurological conditions. The literature on CS is limited. In 1995, Berrios and Luque reported three types of Cotard' syndrome:

Psychotic depression where patients have melancholia and nihilistic delusionsCotard type 1 which are the pure forms of nihilistic delusions without depressive symptomsCotard type 2 with a mixed group of symptoms of anxiety, depression, auditory hallucinations and nihilistic delusions[5],[8]

Our initial impression in this case was postoperative delirium, which is common after any major surgical procedure including head and neck surgery.[9],[10] Postoperative delirium most commonly presents as confusion, disorientation, and fluctuation in cognition, but other symptoms such as agitation and delusions may also be evident.[3]

Delusions in the context of delirium can be of any variety; however, predominantly nihilistic delusions in the absence of pronounced fluctuation in consciousness made us wonder if we were dealing with a case of CS as previously described in the context of abdominal surgery by Sharma and Biswas.[5] Our patient had a premorbid history of complicated grief and mild depression, but the development of nihilistic delusions in the immediate postoperative period hinted towards a relationship between the emergence of CS in wake of previous surgery. Another reason why postoperative delirium was unlikely is that in this case a detailed organic screening had ruled out most of the common causes of delirium.

There is no standard treatment for CS because of its rarity. Pharmacological treatment for CS includes medications such as tricyclic or selective serotonin reuptake inhibito antidepressants when the preexisting condition was depression, whereas if CS developed in the context of preexisting psychotic condition such as schizophrenia, the treatment options would include antipsychotics or electroconvulsive therapy. Spontaneous emergence and resolution of CS is rare but can still happen in postoperative setting, which happened in the present case and a few cases before this.[2],[3],[5] This case report shall help in enhancing the knowledge of this syndrome which will lead to its early identification and improved overall outcome for the patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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