We report the case of a 44-year-old man with bipolar disorder who exhibited reflexia alternans in the setting of electroconvulsive therapy - brisk reflexes in the morning; absent in the evening.

A 44-year-old Korean-American man with bipolar disorder was transferred to our ICU from an outside hospital with difficulty being weaned from the ventilator after being sedated for a lumbar puncture. Upon arrival, exam was consistent with a stuporous catatonia, and our service was consulted to rule out non-convulsive status epilepticus. EEG was unremarkable, and inpatient psychiatry was consulted for further recommendations.

Patient was started on electroconvulsive therapy (ECT) for 5 planned treatments. He became increasingly interactive with each round of treatment, however his daily neurologic exam had begun to show inconsistencies that coincided with these treatments.

Our patient had begun receiving ECT in the morning at 0700. Our service would examine the patient shortly after treatment, and then once again in the afternoon. 

During his morning exam, his reflexes would be brisk bilaterally, 3+ in the brachioradialis, biceps, and triceps tendons. During afternoon rounds, they would appear markedly diminished, trace-to-absent.

*Reflexes in the lower extremities remained brisk and symmetric regardless of time of day.

Transitory neurologic dysfunction, including deep tendon reflex asymmetry, has been described in the literature in patients receiving ECT (Kriss, et al). The duration and intensity of ECT was found to correspond with the duration of the post-ictal effects (which are typically brief, lasting 20-30 min). The result is generally a loss of function - dropped reflexes, paresis, hemianopsia, or aphasia - and this dysfunction is generally referable to the treated hemisphere. Our case is unique in that our patient exhibited gain of function, notably a symmetric increase in reflexes, and of a duration that was more prolonged than expected, lasting at least 1-2 hours.