Carbamazepine in the treatment of neuroleptic malignant syndrome

Theoretical Study of the Geometry of Dibenzoazepine Analogues

The geometry of dibenzoazepine analogues—typical multifunctional drugs—was investigated to find the geometrical parameters sensitive to the substitution of the central seven-membered ring. Exploration of the crystal structure database (CSD) shows that the geometrical parameter sensitive to the substitution of the carbon atom distance of the central ring not included in the aromatic rings to the plane through the carbon atoms common for the central ring and the aromatic side rings. Presence of the double bond in the central ring was reflected in its partial aromaticity expressed by the HOMED parameter. Some derivatives of 5H-dibenzo[b,f]azepine with flat conformation of the central ring are characterized by mobility of the electron density comparable to the mobility in the aromatic side rings. Influence of the surrounding on the investigated compounds was confirmed by comparison of the optimized molecules and the molecules in the crystal state where the packing forces can influence the molecular geometry.

Case reports of neuroleptic malignant syndrome in context of quetiapine use

A retrospective analysis was followed on 20 case reports covering the possible correlation between the atypical antipsychotic, quetiapine, and neuroleptic malignant syndrome (NMS), determined by the study of 7 different NMS criteria guidelines. A great majority (19) of the case studies did not meet the requirements of all 7 guidelines, frequently due to unreported information. Nor was quetiapine proven to be the sole cause of the possible NMS in the two age groups investigated. Only one case was found to have no other medication or medical conditions confounding the relationship of quetiapine and NMS symptoms, and that case was in the context of a significant quetiapine overdose. The other 19 cases demonstrated the difficulty of identifying the cause of NMS when polypharmacy and other medical conditions are involved. The authors note the need for caution in deciding both the presence of NMS and the causal factors of the symptoms.

Neuroleptic malignant syndrome: a review for neurohospitalists

Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. It has been associated with virtually all neuroleptics, including newer atypical antipsychotics, as well as a variety of other medications that affect central dopaminergic neurotransmission. Although uncommon, NMS remains a critical consideration in the differential diagnosis of patients presenting with fever and mental status changes because it requires prompt recognition to prevent significant morbidity and death. Treatment includes immediately stopping the offending agent and implementing supportive measures, as well as pharmacological interventions in more severe cases. Maintaining vigilant awareness of the clinical features of NMS to diagnose and treat the disorder early, however, remains the most important strategy by which physicians can keep mortality rates low and improve patient outcomes.

Combination of Steven-Johnson syndrome and neuroleptic malignant syndrome following carbamazepine therapy: a rare occurrence

Stevens-Johnson syndrome (SJS) is a severe, episodic, acute mucocutaneous reaction that is most often elicited by drugs and occasionally by infections. The drugs commonly implicated as the cause of SJS are anticonvulsants, sulfonamides, non-steroidal anti-inflammatory drugs and antibiotics. Carbamazepine (CBZ) has been commonly implicated in SJS. Neuroleptic malignant syndrome (NMS) is a rare, life-threatening but potentially treatable condition. Among the neuroleptics, haloperidol (parenteral) is implicated as a most common drug for NMS. Though rare, association of NMS with CBZ and association of NMS with toxic epidermal necrolysis (TEN) in a single patient after administration of neuroleptics has been reported in the literature before. However, a combination of NMS and SJS in a single patient after administration of CBZ has not been reported so far. We present a patient with seizure who developed SJS and NMS following administration of CBZ.

Neuroleptic malignant syndrome without fever after addition of oxcarbazepine to long-term treatment with amisulpride

OBJECTIVE

Our goal was to report a case of malignant neuroleptic syndrome in a patient administered with both oxcarbazepine (OXCBZ) and amisulpride (AM).

METHOD

We present a case of a young man who presented with symptoms of malignant neuroleptic syndrome after progressive titration of OXCBZ (1,200 mg) added to the long-term treatment with AM (800 mg).

RESULTS

After discontinuation of AM and administration of dopaminergic drugs, his clinical symptoms improved gradually.

CONCLUSION

This case suggests that clinicians should consider the risk of neuroleptic malignant syndrome when OXCBZ is coadministered to patients undergoing long-term treatment with neuroleptics.

Catatonia and consultation-liaison psychiatry study of 12 cases

Nowadays, catatonia is no more considered as a subtype of schizophrenia. Catatonia seems more frequently associated to mood disorders as well as general medical conditions. It is sometimes difficult to associate formally a medical etiology to this syndrome. But we found, in the literature, three groups of associated general medical conditions: neurological disorders, drug induced and toxic induced conditions, metabolic conditions. We present a prospective study of 12 clinical cases of catatonia due to general medical conditions we realized in the Consultation-Liaison Psychiatry Department of the University Hospital of LILLE (France) during a period of 5 months. We find coherent data with the literature. However, our results suggest that if medical conditions precipitate the catatonia syndrome, they are rarely its only etiology. We think that if somatic factors are co-morbid with psychiatric conditions they do not necessarily predominate as the target of treatment. The treatment of the catatonia must be a priority and remain symptomatic, to allow in parallel the specific treatment for the somatic disorder or the psychiatric disorder.

Drug-induced movement disorders in children and adolescents

The use of psychotropic medication among children and adolescents is increasing with a concomitant increase in the incidence of drug-related movement disorders. This class of adverse reactions to medications can be divided into those that are acute in onset, others that are continuous as long as the offending drug is administered, and a final category consisting of symptoms that are persistent, even after the causative agent has been discontinued. Within these three categories, this review discusses the epidemiology, risk factors, clinical features and treatment of acute dystonic reactions, drug-induced parkinsonism, neuroleptic malignant syndrome, serotonin syndrome, acute akathisia, and the tardive syndromes. In addition, drugs that commonly cause tremor, chorea, or myoclonus are included.

The evaluation and management of patients with neuroleptic malignant syndrome

NMS is a rare but fatal syndrome that needs to be considered in the perioperative period. Although many aspects remain unexplored and controversial, with greater awareness of the condition, new concepts are coming into light. Definitive treatment guidelines remain an important issue to be addressed. Efforts have been initiated in that direction and all cases can be reported on a toll-free hotline ( 1-888-667-8367) or online (www.nmsis.org).

Drug-induced movement disorders in children

The increased use of stimulants, antipsychotic agents, and antidepressant drugs in children by primary care physicians, psychiatrists, and neurologists has inevitably led to increased numbers of pediatric patients manifesting the side effects of these agents, many of which are movement disorders. Unlike the isolated abnormal involuntary movements associated with drugs prescribed for epilepsy or asthma, movement syndromes (eg, acute dystonic reaction, neuroleptic malignant syndrome, serotonin syndrome, tardive dyskinesia) associated with psychotropic drugs are complex, difficult to recognize, and potentially seriously disabling. Accurate clinical identification of these drug-induced syndromes is critical to engaging the proper therapeutic intervention for them.

Is neuroleptic malignant syndrome a neurogenic form of malignant hyperthermia?

Neuroleptic malignant syndrome is a rare and potentially lethal disorder associated with the use of antipsychotic medications. Heightened vigilance on the part of clinical providers has reduced morbidity and mortality caused by this disorder over the past decade, but there is still no consensus regarding its diagnosis, pathophysiology, or treatment. Efforts to demonstrate a direct link between neuroleptic malignant syndrome and malignant hyperthermia have been unsuccessful, indicating mutually distinct etiologies despite striking clinical similarities. This paper concisely reviews essential aspects of electromechanical transduction in muscle and nerve cells and current knowledge concerning the pathophysiology of malignant hyperthermia and neuroleptic malignant syndrome. Utilizing this conceptual framework, the author proposes that neuroleptic malignant syndrome may be caused by a spectrum of inherited defects in genes that are responsible for a variety of calcium regulatory proteins within sympathetic neurons or the higher order assemblies that regulate them. In this proposed model, neuroleptic malignant syndrome may be understood as a neurogenic form of malignant hyperthermia.

Stop that! Inhibition, sensitization, and their neurovisceral concomitants

There is increasing evidence that the behavior of living systems can be conceptualized as a self-organizing dynamical system. Moreover, evidence suggests that inhibitory processes give these systems the flexibility that is necessary for efficient functioning in the face of changing environmental demands. The process of sensitization can be conceived as a breakdown of inhibitory neural processes that can lead to maladaptive, perseverative behavior. In this paper we describe a model of inhibition and sensitization from a dynamical systems perspective. We show that inhibition is important for adaptive behavior across a number of levels of system functioning. Using our work on attention, emotion, and anxiety disorders we show the importance of both central - for example gamma-aminobutyric acid (GABA)-ergic - and peripheral - for example heart rate variability (HRV) - inhibitory processes and how they may be linked by a network of neural structures that guide the organism from one state of relative stability to another.

The neuroleptic malignant and serotonin syndromes

The neuroleptic malignant syndrome and the serotonin syndrome share many clinical features and may exist on a spectrum of the same disorder. The neuroleptic malignant syndrome, however, is an idiosyncratic drug reaction, whereas the serotonin syndrome is an effect of drug toxicity. Both syndromes present with varying degrees of mental status changes and autonomic instability. In general, patients with the neuroleptic malignant syndrome have higher fevers and pronounced extrapyramidal signs with muscle rigidity, whereas patients with the serotonin syndrome have lower fevers, more gastrointestinal dysfunction, and myoclonus. Treatment for both syndromes consists of removing the offending agent and providing intensive supportive care. Syndrome-specific therapies are controversial.