Neuroleptic malignant syndrome: mechanisms, interactions, and causality

Turn Up the Heat: A Case Report of Malignant Hyperthermia During Ambulatory Surgery

Malignant hyperthermia is a rare complication of general anesthesia involving the uncontrolled release of calcium when exposed to triggers such as depolarizing muscle relaxants or volatile anesthetics. It presents as a hypercatabolic skeletal muscle syndrome that results in tachycardia, hyperthermia, hypercapnia, muscle rigidity, acidosis, rhabdomyolysis, and hyperkalemia. This report presents the case of a 67-year-old female without a personal or family history of complications with anesthesia who experienced malignant hyperthermia during an elective hysterectomy. The patient was given multiple doses of dantrolene, with the ultimate resolution of her symptoms several days after surgery. She was discharged one week after surgery.

R, Patel PH, Bazan DZ, Mora A, Samuel N, Mingle AC, Leon LR, Varon J, Surani S. Drug-Induced Hyperthermia Review

Humans maintain core body temperature via a complicated system of physiologic mechanisms that counteract heat/cold fluctuations from metabolism, exertion, and the environment. Overextension of these mechanisms or disruption of body temperature homeostasis leads to bodily dysfunction, culminating in a syndrome analogous to exertional heat stroke (EHS). The inability of this thermoregulatory process to maintain the body temperature is caused by either thermal stress or certain drugs. EHS is a syndrome characterized by hyperthermia and the activation of systemic inflammation. Several drug-induced hyperthermic syndromes may resemble EHS and share common mechanisms. The purpose of this article is to review the current literature and compare exertional heat stroke (EHS) to three of the most widely studied drug-induced hyperthermic syndromes: malignant hyperthermia (MH), neuroleptic malignant syndrome (NMS), and serotonin syndrome (SS). Drugs and drug classes that have been implicated in these conditions include amphetamines, diuretics, cocaine, antipsychotics, metoclopramide, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and many more. Observations suggest that severe or fulminant cases of drug-induced hyperthermia may evolve into an inflammatory syndrome best described as heat stroke. Their underlying mechanisms, symptoms, and treatment approaches will be reviewed to assist in accurate diagnosis, which will impact the management of potentially life-threatening complications.

Neuroleptic malignant-like syndrome associated multiple system atrophy: report on three cases

Background

Multiple system atrophy (MSA) associated with neuroleptic malignant-like syndrome (NMLS) is rare and few cases have been described in the literature.

Case presentation

In the present study, three patients with MSA associated with NMLS were analyzed from January 2012 to January 2020 to characterize their clinical presentations. Data collected from the patients for analysis included general patient history, the fluctuation and severity of disease symptoms, the indicated therapies and disease progression at follow-up. All patients had histories of sudden withdrawal or reduction of levodopa prior to the onset of symptoms. Clinical presentations were characterized by hyperthermia, autonomic dysfunction, worsening of extrapyramidal symptoms, and elevated serum creatine kinase (CK) levels. During hospitalization, one patient rapidly progressed and died, while the other two patients were successfully treated.

Conclusions

Early diagnosis and treatment are very important for patient outcomes in NMLS. Notably, the correct dose and time of administration of dopaminergic medication may be key in treating NMLS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02583-8.

Neuroleptic Malignant Syndrome in a Patient With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Case Report and Review of Related Literature

INTRODUCTION

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe but treatable disease that presents with symptoms similar to neuroleptic malignant syndrome (NMS).

CASE REPORT

We describe a 28-year old female who initially presented with headaches, behavioral changes, anxiety, lip tremors, and rigidity of extremities. She was prescribed with olanzapine and later manifested with neuroleptic malignant syndrome symptoms such as decrease in sensorium, muscle rigidity, hyperthermia and tachycardia. Further investigation showed presence of bilateral ovarian teratoma and anti-NMDAR antibodies in her serum and cerebrospinal fluid. Symptoms resolved after intravenous high-dose methylprednisolone, bilateral oophoro-cystectomy, and intravenous immunoglobulin administration. Overlapping pathological mechanisms of anti- NMDAR encephalitis and NMS were discussed. Ten patients with anti- NMDAR encephalitis and NMS were noted in a review of literature. Prognosis was favorable and intervention ranged from supportive to methylprednisolone and intravenous immunoglobulin administration, plasma exchange and teratoma resection.

CONCLUSION

Anti- NMDAR encephalitis patients are at risk for NMS due to antipsychotic intolerance and other interrelated pathophysiological mechanisms. The overlap between the signs and symptoms of anti-NMDAR encephalitis and NMS poses a diagnostic dilemma and warrants a careful investigation and management.

Serum osmolarity and blood viscosity as a potential explanation for the pathophysiology of neuroleptic malignant syndrome

Background: Neuroleptic malignant syndrome (NMS) is a rare but life-threatening side effect. NMS patients usually develop dehydration and fluid-electrolyte imbalance. In this study, we aimed to investigate serum osmolarity and blood viscosity in patients with NMS.Methods: This was a retrospective case-control study including 32 admissions of 27 patients with the diagnosis of NMS. As a control group, 31 non-NMS episodes of hospitalizations of the same patients were included.Results: Serum osmolarity of NMS group was 301.83 ± 20.27 mOsm/L and control group was 294.20 ± 5.92 mOsm/L. Serum osmolarity of NMS group was statistically significantly higher than the controls (p = .018). Whole blood viscosity (WBV) at high shear rate (HSR) value of NMS group was 16.17 ± 1.48 and control group was 16.50 ± 1.38 (p = .331). Regarding WBV at low shear rate (LSR) values, also no statistically significant difference was observed between groups. LSR values of NMS and control group were 39.86 ± 30.11 and 47.41 ± 28.43, respectively (p = .387).Conclusions: Our findings indicate that serum osmolarity of NMS group was statistically significantly higher than the controls. In terms of blood viscosity, there was no statistically significant difference between groups. Higher serum osmolarity in NMS patients than controls may be a reflection of a relative hemoconcentration in NMS.KEY POINTSNMS is usually associated with dehydration resulting in fluid-electrolyte imbalance.We compared the NMS episodes with non-NMS hospitalizations (as control group) of the same patients.Serum osmolarity was statistically significantly higher in NMS group than the controls.There was no statistically significant difference between groups in terms of blood viscosity.

The hot patient: acute drug-induced hyperthermia

Drugs can cause dysregulation of the hypothalamic–pituitary–adrenal axis which can result in a rise in core temperature This type of hyperthermia is unresponsive to antipyretics and can be complicated by rhabdomyolysis multi-organ failure and disseminated intravascular coagulation

Organic causes of fever such as infection must be ruled out Syndromes associated with drug-induced fever include neuroleptic malignant syndrome and anticholinergic sympathomimetic and serotonin toxicity

The class of offending drugs as well as the temporal relationship to starting or stopping them assists in differentiating between neuroleptic malignant syndrome and serotonin toxicity

Immediate inpatient management is needed The mainstay of management is stopping the drug and supportive care often in the intensive care unit

Neuroleptic malignant syndrome and serotonin syndrome

The clinical manifestation of drug-induced abnormalities in thermoregulation occurs across a variety of drug mechanisms. The aim of this chapter is to review two of the most common drug-induced hyperthermic states, serotonin syndrome and neuroleptic malignant syndrome. Clinical features, pathophysiology, and treatment strategies will be discussed, in addition to differentiating between these two syndromes and differentiating them from other hyperthermic or febrile syndromes. Our goal is to both review the current literature and to provide a practical guide to identification and treatment of these potentially life-threatening illnesses. The diagnostic and treatment recommendations made by us, and by other authors, are likely to change with a better understanding of the pathophysiology of these syndromes.

Fatal Neuroleptic Malignant Syndrome Associated With Quetiapine

Acute psychosis developed in an elderly patient with Parkinson disease and she was admitted and treated with quetiapine (Seroquel). One day later, high fever unexplained by infection appeared associated with restlessness, confusion, convulsion, leukocytosis, and extreme serum creatine kinase levels. She died of neuroleptic malignant syndrome (NMS) despite intensive treatment. Quetiapine is an atypical neuroleptic agent, rarely associated with NMS in the absence of other contributing drugs. Our case strongly establishes quetiapine-induced NMS (Naranjo scale 6) and is also unique in the abrupt onset and severe refractory course. The steep increase in the prescription of quetiapine worldwide mandates better recognition of this severe adverse reaction, which is fortunately rare, to allow immediate drug withdrawal and appropriate treatment.

Fever, confusion, acute kidney injury: is this atypical neuroleptic malignant syndrome following polypharmacy with clozapine and risperidone?

OBJECTIVE

Clozapine is the gold-standard antipsychotic medication for treatment-refractory schizophrenia (TRS). However, one potentially lethal side effect of clozapine, as with other antipsychotics, is neuroleptic malignant syndrome (NMS) which could present differently in clozapine therapy. 'Atypical NMS' is a recognised variant of NMS with less rigidity and delayed elevation of creatine kinase; this variant is associated with clozapine.

METHOD

A case from the author's clinical practice was reviewed.

RESULTS

A 67-year-old man with TRS was treated with clozapine. Unfortunately, his physical condition deteriorated and he presented with atypical NMS, which initially was treated as presumable urinary tract infection.

CONCLUSIONS

Atypical NMS is associated with clozapine. This case exposes the potential difficulties in diagnosis, and highlights the importance of considering less common diagnoses in acutely unwell psychiatric patients.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Potential Mimic of Neuroleptic Malignant Syndrome

BACKGROUND

Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune disorder characterized by behavioral changes, dyskinesia, and autonomic instability.

PATIENT DESCRIPTION

We describe a 14-year-old girl who initially presented with acute behavioral changes and seizures and who over a 2-week period developed high fever, tachycardia, and elevated blood pressures.

RESULTS

Because she received multiple medications including anticonvulsants and a neuroleptic, our patient was initially diagnosed with neuroleptic malignant syndrome, a disorder characterized by autonomic dysfunction, hyperthermia, muscle rigidity, and mental status changes usually caused by the use of a neuroleptic agent. Further investigation, however, revealed the presence of N-methyl-D-aspartate receptor antibodies and an ovarian teratoma. Symptoms resolved after teratoma resection and intravenous immunoglobulin therapy.

CONCLUSION

We propose that anti-N-methyl-D-aspartate receptor encephalitis can cause a paraneoplastic syndrome mimicking neuroleptic malignant syndrome.

[Dementia with Lewy bodies presenting marked tongue protrusion and bite due to lingual dystonia: A case report]

We report the patient of a 53-year-old woman who developed subacute-onset marked tonge protrusion and bite. She was diagnosed as dementia with Lewy bodies (DLB) from the clinical features including progressive cognitive decline, visual hallucinations, parkinsonism, and severe insomnia and depression, and the radiological finding of low dopamine transported uptake in basal ganglia by Dat SCAN and low blood circulation in occipital lobe of cerebrum. The patient received 600 mg doses of levodopa for over a year, followed by rotigotine and ropinirole with a rapid increase of dosage. It is believed that these treatments stimulated and sensitized dopamine D1 receptors, thereby inducing lingual dystonia. Furthermore, the patient demonstrated dyspnea and attacks of apnea caused by the closure of bilateral vocal cords due to laryngeal dyskinesia. After initiation of the neuroleptic, olanzapine, for a short duration, the high dose of levodopa overlapped with neuroleptic sensitivity, suggesting DOPA-induced dystonia and dyskinesia. This interaction can sometimes lead to lethal adverse events, and must be considered very important when treating patients with DLB.

[Pharmacotherapy of psychiatric acute and emergency situations: General principles]

The pharmacotherapy of psychiatric emergencies is essentially determined by the acuteness, the scene of the emergency, the diagnostic assessment and the special pharmacological profile of the drug used. As there are no specific drugs, syndromic treatment is carried out. For this, primarily antipsychotic drugs and benzodiazepines are available. This article gives an overview of the current state of treatment options for major psychiatric emergency syndromes, namely agitation, delirium, stupor and catatonia, anxiety and panic, as well as drug-induced emergencies.

Malignant Subthalamic Nucleus-Deep Brain Stimulation Withdrawal Syndrome in Parkinson's Disease

Abrupt cessation of STN-DBS is an under-recognized cause of life-threatening akinetic crisis in Parkinson's disease (PD) and can present as a movement disorder emergency. We report on 2 patients who survived severe and prolonged akinetic crisis after abrupt cessation of STN stimulation for PD (malignant STN-DBS withdrawal syndrome). We discuss the clinical similarities and possible differences in pathophysiology from the akinetic crisis in medically-treated PD. Although early implantable pulse generator (IPG) replacement is the definitive treatment, medical and economic considerations may preclude early surgery and strategies for medical management assume importance. We reflect upon the socioeconomic concerns surrounding DBS in countries lacking health care coverage and the need for user-independent monitors and indicators of low IPG battery status.

Neurotoxic syndrome induced by clomipramine plus risperidone in a patient with autistic spectrum disorder: serotonin or neuroleptic malignant syndrome?

To the best of our knowledge, there are no case studies of serotonin syndrome (SS) in patients with autism spectrum disorder. We report the case of a 33-year-old male who presented SS under the combined use of clomipramine and risperidone. More specifically, within 2 days after clomipramine (10 mg/BID-two times a day) was added to risperidone (4 mg/OD-once a day), mirtazapine 45 mg/OD and alprazolam (0,5 mg/TID-three times a day) he began to present mental, neurological and autonomic symptoms. All his psychopathological manifestations and laboratory findings normalized after the above-mentioned drugs' discontinuation, and the administration of supportive medical care and lorazepam 2,5 mg/TID. The diagnosis of serotonin syndrome was challenging due to the relatively low dose of clomipramine, an increase of risperidone which had taken place before clomipramine administration and clinical symptoms which could be attributed to both serotonin and neuroleptic malignant syndrome.

Postoperative neuroleptic malignant syndrome-like symptoms improved with intravenous diazepam: a case report

A 75-year-old man who had undergone left upper lobectomy of the lung exhibited fever and insomnia on postoperative day (POD) 1 and muscle rigidity, autonomic instability, and somnolence on POD2 after epidural administration of droperidol and withdrawal of oral etizolam. He had not been known to have any neuromuscular diseases or psychiatric diseases, with the exception of anxiety disorder. Brain computed tomography did not show cerebrovascular disorders. Consultation with a neurologist led to a suspicion of neuroleptic malignant syndrome (NMS). Epidural droperidol was stopped and administration of dantrolene was initiated. These measures, in addition to supportive care, only partially ameliorated the symptoms of the patient, and consciousness disturbance developed; the patient finally became comatose on POD3. However, intravenous diazepam (10 mg) improved his symptoms abruptly. Subsequently, oral administration of lorazepam (1 mg/day) was started, and his symptoms disappeared within 2 days (POD5). Although NMS-like symptoms are rarely seen in clinical practice, some factors may induce it during the perioperative period, such as the administration of dopamine antagonists and the cessation of benzodiazepines. Intravenous diazepam is an effective treatment in cases with suspected gamma-aminobutyric acid (GABA) hypoactivity at the GABA_A receptor induced by the cessation of benzodiazepines.

Diagnosis and treatment of drug-induced hyperthermia

PURPOSE

The etiology, pathophysiology, clinical presentation, and management of drug-induced hyperthermia (DIH) syndromes are reviewed.

SUMMARY

DIH syndromes are a rare and often overlooked cause of body temperature elevation and can be fatal if not recognized promptly and managed appropriately. There are five major DIH syndromes: (1) neuroleptic malignant syndrome, (2) serotonin syndrome, (3) anticholinergic poisoning, (4) sympathomimetic poisoning, and (5) malignant hyperthermia. The differential diagnosis of DIH syndromes can be challenging because symptoms are generally nonspecific, ranging from blood pressure changes and excessive sweating to altered mental status, muscle rigidity, convulsions, and metabolic acidosis. Evidence from the professional literature (per a MEDLINE search for articles published through November 2011) indicates that few currently available treatment options can reduce the duration of hyperthermia; therefore, prompt identification of the provoking agent based on the patient's medication history, the clinical presentation, and the timing of symptom onset is essential to determine the appropriate treatment and mitigate potentially life-threatening sequelae. For all DIH syndromes, appropriate management includes the immediate discontinuation of the suspected offending agent(s) and supportive care (external cooling, volume resuscitation as needed); in some cases, pharmacologic therapy (e.g., a benzodiazepine, bromocriptine, dantrolene) may be appropriate, with the selection of a specific agent primarily determined by the medication history and suspected DIH syndrome.

CONCLUSION

DIH is a hypermetabolic state caused by medications and other agents that alter neurotransmitter levels. The treatment of DIH syndromes includes supportive care and pharmacotherapy as appropriate.

Delirium followed by neuroleptic malignant syndrome in rehabilitation setting. Is it anger reaction before discharge?

Delirium and neuroleptic malignant syndrome (NMS) are two uncommon syndromes that are often unrecognized or misdiagnosed by the primary physicians as functional psychiatric disorders. The infrequency and the heterogeneity of clinical manifestation, progression and outcome with which those diagnoses are encountered (particularly in chronic rehabilitation settings) make them formidable diagnostic challenge. In this report, we present a case in which there was a misdiagnosis of delirium and NMS as functional psychiatric disorders. This report demonstrates the fact that early recognition and intervention in such cases are essential to prevent the grave outcome and potential fatality. The authors believe that there is a key role for the consulting psychiatrist in this area in providing diagnostic clarity and advice regarding management and ongoing staff education.

Inpatient management of Parkinson disease: current challenges and future directions

Parkinson disease (PD) is usually managed through outpatient clinical care. Reasons for hospital admissions are either directly related to PD or may reflect comorbidities. When hospitalized, patients with PD may face many challenges. Most commonly these are related to medication management, falls, mental status changes, infections, and emergence of psychiatric symptoms. Timely recognition and proper management of PD-specific hospitalization-related problems may be delayed, given the common lack of expertise in PD management of hospital physicians, nurses, and allied health professionals. With increasing prevalence of PD, it is expected that more patients will require inpatient hospital care. It is therefore very important to recognize problems that may arise upon hospitalization of a patient with PD and provide education to health care professionals involved in the inpatient care of patients with PD. This approach may lead to reductions in complication rates and duration of hospital stays.

AIM

In this review, we outline the most common reasons for hospitalization of patients with PD, discuss challenges related to inpatient hospital care of patients with PD, and comment on future directions aimed at optimizing hospitalization outcomes in the population with PD.

Neuroleptic malignant syndrome following combination of sertraline and paroxetine: a case report

Neuroleptic malignant syndrome (NMS) is a rarely observed life-threatening medical condition due mostly to antipsychotic use. Additionally, a few case reports have suggested an association between NMS and the use of selective serotonin reuptake inhibitors (SSRIs) alone or in combination with antipsychotics. This case report presents a female patient developing NMS following the use of a combination of sertraline and paroxetine.

[Hypothermia under olanzapine treatment: clinical case series and review of current literature]

BACKGROUND

Antipsychotic drugs may lead to hypothermia as well as hyperthermia. Although known for decades and clinically highly relevant, the mechanisms by which antipsychotic drugs alter thermoregulatory processes in the human body are still far from being fully understood. In clinical practice, much attention is paid to antipsychotic drug-induced elevation of body core temperature as observed in the neuroleptic malignant syndrome (NMS). But also hypothermia is a clinically highly relevant adverse reaction to antipsychotic drugs.

MATERIAL AND METHODS

Here we report a case series of three patients who developed severe hypothermia after administration of olanzapine. A review of the current literature is given with a focus on risk factors for the development of antipsychotic drug-induced hypothermia and its pathophysiologic mechanisms.

RESULTS

A 51-year-old female patient suffering from catatonic schizophrenia, cachectic nutritional condition and hypothyroidism developed severe hypothermia of 30.0°C body core temperature after administration of 30 mg olanzapine per day under comedication with lorazepam and L-thyroxine. A 48-year-old female patient with catatonic schizophrenia showed hypothermia of 31.0°C (rectal measurement) after single-dose administration of olanzapine 10 mg orally and a total of 3 mg lorazepam (1-1-1 mg). The third case report describes a 69-year-old male patient with acute delusional disorder exhibiting hypothermia of 33.0°C (rectal measurement) in combination with a reversible atrioventricular block grade III without any further comedication.

CONCLUSION

A review of the current literature reveals that thermoregulatory disturbances as sequelae of antipsychotic drug administration depend on individual disposition as well as various independent risk factors such as environmental temperature, somatic comorbidities, endocrinological abnormalities (e.g. hypothyroidism) and structural damage of the brain. A complex interaction of dopaminergic regulatory mechanisms in the ventral hypothalamus and peripheral vaso- and sudomotor adjustments seems to be causative. Hypothermia following antipsychotic drug administration represents a serious adverse drug reaction and a potentially life-threatening event.

Miscellaneous central nervous system intoxicants

The topic of central nervous system intoxicants encompasses a multitude of agents. This article focuses on three classes of therapeutic drugs, with specific examples in which overdoses require admission to the intensive care unit. Included are some of the newer antidepressants, the atypical neuroleptic agents, and selected anticonvulsant drugs. The importance of understanding pertinent physiology and applicable supportive care is emphasized.

Neuroleptic malignant syndrome-an 11-year longitudinal case-control study

OBJECTIVE

To describe patients with neuroleptic malignant syndrome (NMS), to establish occurrence of NMS, to investigate risk factors of NMS, and to investigate mortality associated with NMS.

METHOD

We conducted a longitudinal register linkage case-control study of NMS.

RESULT

In health care registers covering the period from 1996 to 2007, we identified, among 224 372 patients with organic, psychotic, affective, or neurotic diagnosis, 83 patients with NMS, equivalent to an occurrence of 0.04%. Treatment with second-generation antipsychotics (SGAs) in the 3 months preceding admission increased the NMS risk (OR 4.66; 95% CI 1.96 to 11.10) and also first-generation antipsychotics (FGAs) of high potency (OR 23.41; 95% CI 5.29 to 103.61) and mid potency (OR 4.81; 95% CI 1.96 to 11.79), and depot antipsychotics (OR 4.53; 95% CI 1.60 to 12.80). Benzodiazepines (BDZs) also increased the risk of NMS (OR 3.43; 95% CI 1.68 to 12.80). NMS was associated with an increased mortality (HR 1.88; 95% CI 1.19 to 2.98) in patients, compared with sex-, age-, and diagnosis-matched control subjects, but no significant difference in mortality between patients and control subjects was observed after the initial 30 days (P = 0.27).

CONCLUSIONS

The occurrence of NMS is low, and the prediction of NMS is difficult. Previous treatment with FGAs, SGAs, and BDZs was identified as a risk factor for developing NMS. NMS increased mortality within 30 days after NMS.

Anesthetic management of a pediatric patient with neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a rare disorder which is clinically similar to malignant hyperthermia (MH). It is characterized by hyperthermia, autonomic instability, muscle rigidity, coma, rhabdomyolysis, and acidosis. Without immediate and appropriate therapy, mortality may result. NMS is associated with administration of antipsychotic medications, anti-emetic medications, and changes in the dosage of anti-parkinsonian drugs. As several similarities exist between NMS and MH, differentiating between them can be a challenge for the clinician. We report anesthetic care during magnetic resonance imaging of the brain of a 14-year-old female with bipolar and schizoaffective disorders and the recent onset of NMS.

Hypothermia associated with antipsychotic drug use: a clinical case series and review of current literature

Hypothermia as an adverse reaction of antipsychotic drug use represents a potentially life-threatening complication. However, the mechanisms by which antipsychotic drugs alter thermoregulatory processes in the human body are far from being fully understood. Here we present a case series of 5 patients developing severe hypothermia after administration of olanzapine and benperidol. Controlled by a network of neural structures, body temperature is physiologically regulated in far more narrow boundaries than are other vital functions, and its homeostasis is critical for survival. The preoptic region in the ventral hypothalamus is assumed to act as a coordinating center that is endowed with thermosensory units that constantly compare actual body temperature with target values and initiate regulatory and compensatory mechanisms in case of mismatch. Hypothermia risk seems to increase in the first days after initiation of antipsychotic drug therapy or increases in the daily dose. Schizophrenic patients bear a higher risk than nonschizophrenic patients treated with antipsychotic drugs (such as patients with dementia or depression). Antipsychotic drugs with strong 5-HT2 antagonism seem to be more frequently associated with hypothermia. These cases demonstrate the clinical relevance of hypothermia as an adverse reaction to antipsychotic treatment and the importance of careful monitoring of body temperature.

Neuroleptic malignant syndrome associated with bromocriptine withdrawal in Parkinson's disease--a case report

A 74-year-old man had 15-year history of Parkinson's disease and received bromocriptine monotherapy for 3 years. We present the first case report of neuroleptic malignant syndrome associated with the withdrawal of bromocriptine. The symptoms were alleviated by adequate replenishment of intravenous fluid, temperature reduction and replacement of bromocriptine. Clinicians need to be aware of this potential complication and that a thorough history of current medications is crucial to its identification.

Selective cerebellar and basal ganglia injury in neuroleptic malignant syndrome

BACKGROUND AND PURPOSE

High core body temperatures have been shown to selectively damage the cerebellum and basal ganglia in malignant hyperthermia, but involvement of both areas in neuroleptic malignant syndrome (NMS) has not been described.

METHODS

Here, we report a case of acute cerebellar and basal ganglia injury by magnetic resonance imaging (MRI) in the setting of NMS. We discuss the pathophysiology, both of NMS and hyperthermic brain injury.

RESULTS

MRI showed new restricted diffusion in cerebellar hemispheres bilaterally and right basal ganglia when compared with brain MRI obtained 1 month prior. T2 FLAIR hyperintensities corresponding to diffusion restriction were also seen in the cerebellum.

CONCLUSIONS

Both the basal ganglia and cerebellum can be injured selectively in NMS.