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Abstract
Malignant hyperthermia and neuroleptic malignant syndrome, two hyperthermic syndromes, are discussed with respect to their pathogenesis, pathophysiological factors, diagnosis, differential diagnosis, and treatment. Malignant hyperthermia is a drug- or stress-induced hypermetabolic syndrome characterized by vigorous muscular contractures and cardiovascular collapse. Neuroleptic malignant syndrome results primarily from an imbalance of central neurotransmitters caused by neuroleptic drug use and characterized by mental status changes and muscular rigidity. Recognition and prompt treatment of these disorders reduces their morbidity and mortality.
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Affiliation(s)
- Frederick J. Curley
- Pulmonary Medicine Division, University of Massachusetts Medical School, Worcester, MA
| | - Richard S. Irwin
- Pulmonary Medicine Division, University of Massachusetts Medical School, Worcester, MA
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3
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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal form of drug-induced hyperthermia characterised by mental status changes, muscle rigidity, hyperthermia and autonomic dysfunction. Increased awareness and early recognition will lead to prompt management. The diagnosis of NMS presents a challenge because several medical conditions generate similar symptoms. The presentation and course of NMS can be quite variable ranging from a stormy and potentially fatal course to a relatively benign and self-limiting course. The most important aspect of treatment is prevention. This includes reducing risk factors (e.g. dehydration, agitation and exhaustion), early recognition of suspected cases and prompt discontinuation of the offending agent. All patients with psychosis should be monitored daily for dehydration and elevated temperature, have vital signs checked and agitation should be watched for. Antipsychotics should be used conservatively with gradual titration of doses. The management of NMS should be based on a hierarchy of symptom severity. Following an episode of NMS, the patient should be reassessed for further treatment with antipsychotics and rechallenge should not be attempted at least 2 weeks following resolution of symptoms of NMS. The patient and family should be educated about the episode and consent for further medication use obtained after a clear explanation of the risk-benefit analysis.
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4
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Ellenbroek BA. Treatment of schizophrenia: a clinical and preclinical evaluation of neuroleptic drugs. Pharmacol Ther 1993; 57:1-78. [PMID: 8099741 DOI: 10.1016/0163-7258(93)90036-d] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Forty years after the first clinical report on the effectiveness of chlorpromazine in psychiatric patients, neuroleptic drugs are still the most widely used drugs in the treatment of schizophrenia. Indeed, there are no other drugs which have proven to be as effective in the treatment of this severe psychiatric disorder. Yet, there are still many unresolved problems relating to neuroleptic drugs. The present review gives a comprehensive overview of our knowledge (and our lack of knowledge) with respect to the clinical and preclinical effects of neuroleptic drugs and tries to integrate this knowledge in order to identify the neuronal mechanisms underlying the therapeutic and side effects of neuroleptic drugs.
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Affiliation(s)
- B A Ellenbroek
- Department of Psycho- and Neuropharmacology, Catholic University of Nijmegen, The Netherlands
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5
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Abstract
Many clinical features of the neuroleptic malignant syndrome suggest that sympathetic nervous system hyperactivity is involved in the pathophysiology of this disorder. Only a few studies have examined levels of catecholamines or their metabolites in patients with NMS; results so far have been inconclusive. In the present study urinary catecholamine metabolites obtained during the course of NMS were studied with respect to frequently reported signs and symptoms of NMS. The principal findings are that (1) elevated urinary catecholamines and metabolites are a frequent but inconstant feature of NMS; (2) it is likely that sympathetic nervous system hyperactivity contributes to the picture of fulminant NMS; and (3) the role of the adrenal medulla in producing excess catecholamines during NMS is uncertain.
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Affiliation(s)
- R J Gurrera
- Department of Veterans' Affairs Medical Center, Brockton, Massachusetts 02401
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Gradon JD. Neuroleptic malignant syndrome possibly caused by molindone hydrochloride. DICP : THE ANNALS OF PHARMACOTHERAPY 1991; 25:1071-2. [PMID: 1803792 DOI: 10.1177/106002809102501008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The case of a patient who developed neuroleptic malignant syndrome (NMS) on three separate occasions is presented. Her third bout of this syndrome possibly was caused by molindone hydrochloride. This medication has been reported only once previously to cause NMS. The pharmacology of molindone is reviewed and a complicating factor in this case--the recent onset of hypothyroidism--is discussed together with its implication in the development of the clinical manifestations of this syndrome.
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Affiliation(s)
- J D Gradon
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY 11219
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Fleischhacker WW, Unterweger B, Kane JM, Hinterhuber H. The neuroleptic malignant syndrome and its differentiation from lethal catatonia. Acta Psychiatr Scand 1990; 81:3-5. [PMID: 2184638 DOI: 10.1111/j.1600-0447.1990.tb06439.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Neuroleptic malignant syndrome and lethal catatonia are potentially life-threatening diseases with similar clinical features, including fever, akinesia and rigidity. Differential diagnosis is difficult but possible by exact clinical observation and a detailed history of the 2 weeks prior to the onset of illness.
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Ebadi M, Pfeiffer RF, Murrin LC. Pathogenesis and treatment of neuroleptic malignant syndrome. GENERAL PHARMACOLOGY 1990; 21:367-86. [PMID: 1974219 DOI: 10.1016/0306-3623(90)90685-f] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1. Neuroleptic drugs (antipsychotics) produce numerous side effects which include serious extrapyramidal symptoms consisting of akathisia, dystonia, neuroleptic malignant syndrome, parkinsonian reactions such as postural abnormality, tremor, akinesia or bradykinesia, rigidity, and tardive dyskinesia. 2. Among the complications of neuroleptic chemotherapy, the most serious and potentially fatal complication is malignant syndrome, which is characterized by extreme hyperthermia, "lead pipe" skeletal muscle rigidity causing dyspnea, dysphagia, and rhabdomyolysis, autonomic instability, fluctuating consciousness, leukocytosis, and elevated creatine phosphokinase. 3. Neuroleptic malignant syndrome should be differentiated from malignant hyperthermia, lethal catatonia, and other pathological states producing some of these same symptoms. 4. In addition to neuroleptics, malignant syndrome has been caused by thymoleptics (antidepressants), metoclopramide (antiemetic), metoclopramide combined with cimetidine, tetrabenazine, overdosage of benzodiazepine, phenelzine, dothiepin and alcohol, and amphetamine. 5. Factors leading to and/or facilitating the emergence of neuroleptic malignant syndromes are reportedly organic brain syndrome, dehydration, exhaustion, external heat load, excessive sympathetic discharge, use of long acting neuroleptics, high doses of neuroleptics, rapid dose titration with neuroleptics, abrupt discontinuation of antiparkinsonism agents, and concurrent lithium therapy. 6. Although, the pathogenesis of neuroleptic malignant syndrome is not understood completely, a blockade of dopaminergic receptors in the hypothalamus, spinal cord and striatum, an alteration of dopaminergic-serotonergic transmission in the body, an enhanced synthesis and action of prostaglandin E1 and E2, and a modification of calcium-mediated signal transduction in the body have been suggested. 7. The treatment of malignant syndrome includes immediate withdrawal of neuroleptic drugs, i.v. infusion of dantrolene, and oral administration of bromocriptine; or alternatively i.v. infusion of dantrolene and the combination of levodopa-carbidopa. 8. Other measures to enhance the therapeutic effectiveness of the aforementioned regimens are to include the use of anticholinergic drugs such as benztropine to enhance the effectiveness of bromocriptine, of lorazepam if catatonic symptoms persist, or of electroconvulsive therapy (ECT) if psychotic symptoms persist. 9. These treatments, however, must be "active" rather than "passive", in order to avert fatalities and/or unfortunate sequelae from this iatrogenic and incompletely understood disease.
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Affiliation(s)
- M Ebadi
- Department of Pharmacology, University of Nebraska College of Medicine, Omaha 68105
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9
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Slack T, Stoudemire A. Reinstitution of neuroleptic treatment with molindone in a patient with a history of neuroleptic malignant syndrome. Gen Hosp Psychiatry 1989; 11:365-7. [PMID: 2507394 DOI: 10.1016/0163-8343(89)90125-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The decision to reinstitute neuroleptic treatment in patients with a history of neuroleptic treatment is fraught with hazards. A case is reported in which neuroleptic treatment was successfully reintroduced with molindone after previous bouts of neuroleptic malignant syndrome (NMS) with trifluoperazine and thioridazine. Molindone may represent an alternative neuroleptic to consider in patients with a history of NMS, although all neuroleptics including clozapine and molindone may potentially precipitate this syndrome.
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Affiliation(s)
- T Slack
- Medical Psychiatry Unit, Emory University Hospital, Atlanta, Georgia
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10
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Padgett R, Lipman E. Use of neuroleptics after an episode of neuroleptic malignant syndrome. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1989; 34:323-5. [PMID: 2736477 DOI: 10.1177/070674378903400411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The authors report a case of unequivocal Neuroleptic Malignant Syndrome, in which the patient was successfully rechallenged with a different potent neuroleptic in substantial dosage during the recovery phase. The Neuroleptic Malignant Syndrome did not recur and the patient's psychosis cleared. Reference is made to the relevant world literature.
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Affiliation(s)
- R Padgett
- Department of Psychiatry, McMaster University, Hamilton, Ontario
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Wells AJ, Sommi RW, Crismon ML. Neuroleptic rechallenge after neuroleptic malignant syndrome: case report and literature review. DRUG INTELLIGENCE & CLINICAL PHARMACY 1988; 22:475-80. [PMID: 2899492 DOI: 10.1177/106002808802200606] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Neuroleptic malignant syndrome (NMS) is associated with essentially all of the currently available antipsychotic agents. The signs and symptoms associated with the syndrome are hyperpyrexia, defined by body temperature greater than 38 degrees C; extreme muscle rigidity, with or without elevated creatine phosphokinase or hyperreflexia; and other symptoms such as altered level of consciousness and/or autonomic dysfunction as manifested by labile blood pressure, tachycardia, tachypnea, urinary or fecal incontinence, pallor, or diaphoresis. This potentially fatal syndrome complicates the treatment of patients with recurrent psychotic symptoms because of the possibility for recurrence of the NMS. A case of recurrent NMS is presented in which the patient was rechallenged with an antipsychotic agent. In addition, 41 reported cases of antipsychotic rechallenge after NMS are reviewed. The results of the review suggest that neuroleptic rechallenge following NMS is associated with an acceptable risk of recurrence in most patients. However, close monitoring for NMS and careful selection of patients for antipsychotic rechallenge is mandatory. A minimal time period of five days before rechallenge may also reduce the risk of recurrent NMS. Recurrence was not associated with patient age or gender, nor the antipsychotic agent used.
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Affiliation(s)
- A J Wells
- University of Texas Health Science Center, San Antonio
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Abstract
Neuroleptic malignant syndrome is a potentially fatal consequence of neuroleptic use that has recently gained wide attention. In this article the authors critically review the previous literature and analyze all case reports in the English-language literature (115 cases) for 43 variables. The results are discussed in light of prior literature, and recommendations are made for future research.
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Gibb et al reply. J Neurol Psychiatry 1987. [DOI: 10.1136/jnnp.50.4.504-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Neuroleptic malignant syndrome and early autonomic dysfunction. Acta Psychiatr Scand 1987; 75:447-8. [PMID: 3591427 DOI: 10.1111/j.1600-0447.1987.tb02816.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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15
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Abstract
Neuroleptic Malignant Syndrome is a disabling reaction to neuroleptic drugs recently discussed in psychiatric literature in Europe, Japan, and the United States. It is rare but potentially fatal and is more likely to occur in men, especially young men, than in women. The cause is unknown, but dopamine depletion in the brain is suspected. Treatment usually begins by withdrawing the neuroleptics and then providing supportive therapy for the usual symptoms of high fever, muscular rigidity, labile blood pressure, and tachycardia. The Neuroleptic Malignant Syndrome usually lasts two to three weeks.
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Lazarus A. The neuroleptic malignant syndrome: a review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1986; 31:670-4. [PMID: 3536069 DOI: 10.1177/070674378603100715] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
An overview of the neuroleptic malignant syndrome (NMS) is presented. Its clinical manifestations, pathogenesis, and current treatment are discussed. An increased appreciation of the syndrome may result in more timely interventions and reduce morbidity and mortality in this disorder.
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Pelonero AL, Levenson JL, Silverman JJ. Neuroleptic therapy following neuroleptic malignant syndrome. PSYCHOSOMATICS 1985; 26:946-7. [PMID: 4089133 DOI: 10.1016/s0033-3182(85)72761-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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21
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Abstract
We present the case of a 35-year-old man who developed symptoms of the neuroleptic malignant syndrome (NMS) after taking prescribed, moderately high, therapeutic doses of haloperidol. When brought to the emergency department, he was comatose, hypotensive, and had rigid muscle tone and a core body temperature of 42.2 C. Although initial treatment was supportive, intubation, ventilator support, and further care in the intensive care unit were necessary. Ensuing disseminated intravascular coagulation was treated successfully and the patient was weaned from the ventilator on the third day after admission. He was discharged from the hospital 11 days after admission. Recently recognized drug therapy for NMS, such as bromocriptine mesylate and dantrolene sodium, was not used in this case.
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Aizenberg D, Shalev A, Munitz H. The aftercare of the patient with the neuroleptic malignant syndrome. Br J Psychiatry 1985; 146:317-8. [PMID: 2985164 DOI: 10.1192/bjp.146.3.317] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The neuroleptic malignant syndrome (NMS) is an idiosyncratic reaction to neuroleptic drugs, made up of hyperthermia, muscular rigidity, disturbance of level of consciousness and autonomic dysfunction. It is potentially lethal and should be kept in mind whilst using anti-psychotic drugs; as most patients treated by them require further anti-psychotic treatment, the clinician faces the problem of treating those patients after a NMS episode, yet reports in the literature have generally neglected the problem of late management. A patient suffering from a psychosis and NMS is presented, and a rationale for management offered.
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Abstract
Neuroleptic Malignant Syndrome, a serious and sometimes fatal complication, has been reported to occur in some patients with the administration of neuroleptic medications. Clinically it is manifested by four groups of symptoms which include muscular hypertonicity, autonomic instability, altered consciousness, and hyperthermia. Laboratory findings such as elevated creatinine phosphokinase and leukocytosis are also seen. While it is true that the incidence of the full blown clinical picture of this syndrome is rare, the authors report that only muscular hypertonicity and autonomic instability have occurred frequently in their setting leading to discontinuation of neuroleptics. Such abortive cases may go undetected. If properly diagnosed, the occurrence of this syndrome is not as rare as the published reports indicate. Second, it is reported that rechallenge with neuroleptics may not induce Neuroleptic Malignant Syndrome again. The authors noted recurrence of fever after rechallenge with a different neuroleptic drug. This article describes the method of early recognition and prevention of morbidity as well as mortality.
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Clark WG, Lipton JM. Changes in body temperature after administration of amino acids, peptides, dopamine, neuroleptics and related agents: II. Neurosci Biobehav Rev 1985; 9:299-371. [PMID: 2861591 DOI: 10.1016/0149-7634(85)90052-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This survey begins a second series of compilations of data regarding changes in body temperature induced by drugs and related agents. The information listed includes the species used, the route of administration and dose of drug, the environmental temperature at which experiments were performed, the number of tests, the direction and magnitude of change in body temperature and remarks on the presence of special conditions, such as age or brain lesions. Also indicated is the influence of other drugs, such as antagonists, on the response to the primary agent. Most of the papers were published since 1978, but data from many earlier papers are also tabulated.
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Birkhimer LJ, DeVane CL. The neuroleptic malignant syndrome: presentation and treatment. DRUG INTELLIGENCE & CLINICAL PHARMACY 1984; 18:462-5. [PMID: 6145570 DOI: 10.1177/106002808401800601] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The neuroleptic malignant syndrome is a potentially lethal reaction following the use of antipsychotic medications. The four cardinal signs are hyperthermia, muscular rigidity, autonomic dysfunction, and altered consciousness. The differential diagnosis of the syndrome includes malignant hyperthermia of anesthesia, heat stroke, and acute lethal catatonia. Treatment consists of prompt recognition of the syndrome and initiation of intense supportive measures to manage the hyperthermia and prevent secondary complications. Clinical reports describing beneficial results from use of anticholinergic agents, amantadine, bromocriptine, and dantrolene are reviewed.
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Morrant JC. A catatonic syndrome resulting in death. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1984; 29:147-50. [PMID: 6722708 DOI: 10.1177/070674378402900214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A patient is described who presented with post-partum catatonic schizophrenia and who later became comatose and died with hyperthermia. The differential diagnosis of catatonic stupor is notoriously difficult. The clinical picture somewhat resembled Stauder 's lethal catatonia, doubtless a syndrome secondary to various encephalopathies rather than a disease sui generis . The differential diagnosis is discussed with special emphasis on herpes virus encephalitis and the rare but very important neuroleptic malignant syndrome, which is often unrecognized but for which specific treatment may be available.
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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening complication of neuroleptic therapy. Its occurrence is not familiar to most emergency physicians. Early recognition and appropriate management of NMS may prevent significant morbidity and mortality.
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Scarlett JD, Zimmerman R, Berkovic SF. Neuroleptic malignant syndrome. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1983; 13:70-3. [PMID: 6136267 DOI: 10.1111/j.1445-5994.1983.tb04554.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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