Neuroleptic malignant syndrome

Neuroleptic malignant syndrome induced by donepezil in a patient treated with risperidone and trazodone

Neuroleptic malignant syndrome (NMS) is an uncommon but serious adverse effect that is mainly associated with antipsychotics. NMS induced by donepezil, an acetylcholine esterase inhibitor, has been rarely reported. We describe the case of an elderly man with NMS that developed after starting donepezil. He had been taking risperidone and trazodone for psychosis and depression. 12 days before his presentation, donepezil (3 mg/day) was started, and 7 days later, the dose was increased to 5 mg/day. 2 days later, he became drowsy, and all medications were terminated. 2 more days later, he developed fever and muscle rigidity. His creatine kinase level increased. The patient was diagnosed with NMS and treated with intravenous fluids. He recovered in a few days. Risperidone and trazodone were resumed, but NMS did not recur. Donepezil can induce NMS either alone or when used in combination with some antipsychotics.

Contemporary Perspectives in Critical Care of Neuroleptic Malignant Syndrome

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a psychiatric-neurologic emergency that may require intensive care management. There is a paucity of information about NMS as a critical illness. We reviewed the Mayo Clinic experience.

METHODS

A comprehensive data extraction was completed within the Mayo Clinic system diagnosed with NMS using International Classification of Diseases, ninth revision (ICD-9); ICD-9, Clinical Modification; ICD-10; ICD-10, Clinical Modification; and Health Insurance Claim (HIC) codes between the years of 1995 and 2023. Major criteria included fever, rigidity, tachycardia, and exposure to a neuroleptic agent. Minor criteria included rhabdomyolysis and dysautonomia. Criteria for exclusion were Parkinson's disease, abrupt discontinuation of baclofen or levodopa, concomitant selective serotonin reuptake inhibitors use or serotonin syndrome, malignant catatonia, or a classic dystonic reaction.

RESULTS

A total of 332 patients had diagnostic codes of NMS, but only 20 patients fulfilled DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision), diagnostic criteria. The average age was 48.2 years (range 20-93 years). Four patients received antipsychotics following postoperative acute agitation or delirium (20%). Previous psychiatric diagnoses were schizophrenia or schizoaffective disorder in six patients (33%), major depressive disorder in five patients (20%), and bipolar disorder in two patients (10%). Haloperidol was the sole inciting neuroleptic in five patients (25%), but the remainder was associated with atypical or second-generation antipsychotics. A total of nine patients (45%) required mechanical ventilation. The majority of patients had rhabdomyolysis, which led to acute kidney failure in nearly half of them, but none required hemodialysis. Most patients recovered promptly, and no fatalities were directly attributable to NMS; however, four patients (20%) died within 1 month, and four patients died years from diagnosis and unrelated to NMS.

CONCLUSIONS

Neuroleptic malignant syndrome can become a critical illness, but there is often rapid recovery. Mortality proximate to NMS was uncommon, but late mortality remained substantial. The overwhelming majority of cases coded as NMS did not meet DSM-5 diagnostic criteria. Stricter criteria should be applied when diagnosing NMS in critical care and emergency medicine settings.

Serotonin syndrome caused by escitalopram in Parkinson's disease psychosis: a case report

BACKGROUND

Serotonin syndrome and Parkinson's disease (PD) are two diseases whose symptoms partially overlap; this poses challenges in distinguishing them in clinical practice. Early manifestations such as tremor, akathisia, diaphoresis, hypertonia and hyperreflexia are common in mild-to-moderate serotonin syndrome and can also occur in PD. Without prompt recognition and treatment, serotonin syndrome can rapidly progress, potentially leading to severe complications such as multiple organ failure within hours. Given their disparate treatment strategies, accurate clinical distinction is crucial for effective treatment. This case study explores a patient with serotonin syndrome triggered by escitalopram in the context of PD psychosis (PDP), providing insights into diagnosis and treatment planning.

CASE PRESENTATION

A 75-year-old Asian woman with a one-year history of PD, a two-month history of PDP, and a six-year history of depression presented with symptoms including hyperreflexia, tremor, hypertonia, impaired level of consciousness, and inappropriate behavior following a recent one-month adjustment in medication. Initially suspected of being drug-induced parkinsonism or worsening PD, therapeutic drug monitoring revealed warning levels of escitalopram. Subsequent diagnoses confirmed serotonin syndrome. This syndrome may result from increased cortical serotonin activity at the serotonin2A receptor due to dopamine and serotonin imbalances in PDP, compounded by increased dopamine-mediated serotonin release. Additionally, being an intermediate metabolizer of cytochrome P450 enzyme 2C19, the patient experienced excessive escitalopram accumulation, exacerbating her condition.

CONCLUSIONS

This case underscores the critical need to differentiate between symptoms of serotonin syndrome and PD, particularly in manifestations like tremor and hypertonia. Careful consideration of receptor profiles in patients with PDP is essential when selecting antidepressants to mitigate the risk of serotonin syndrome.

Neuroleptic Malignant Syndrome: An Intensive Care Unit Case of Exceptionally High Creatinine Kinase and Myoglobin Levels

Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening neurologic emergency known to be related to the administration or sudden withdrawal of dopaminergic medications. The clinical course, symptoms, and bloodwork are very heterogeneous, making this syndrome difficult to identify. Thus, NMS is a diagnosis of exclusion. We present a case of severe NMS with exceptionally high creatinine kinase (CK) and myoglobin levels with unclear etiology and a challenging differential diagnosis. Also, our case stands out because it was serious, unique, and had a favorable outcome, which could contribute to the management of future similar cases.

Neuroleptic Malignant Syndrome in Patients With Dementia: Experiences of A Single Memory Clinic

OBJECTIVES

Neuroleptic malignant syndrome (NMS) is a life-threatening condition that occurs as an adverse reaction to antipsychotic and antiemetic agents or sudden withdrawal of dopaminergic medications. Given the metabolic and functional reserves and the comorbidities in older adults, NMS may show an atypical course.

METHODS

The medical records of patients with neurodegenerative diseases leading to dementia between 2013 and 2020 were reviewed for the diagnosis of NMS. Demographic and clinical characteristics of the patients were obtained from the records of laboratory parameters, management, and length of stay.

RESULTS

Fifteen older adults (19 episodes) diagnosed with NMS were included. The median age was 76 years, and 5 were female. Ten of 15 NMS patients were atypical. Most of them had an infection accompanying NMS. Neuroleptic malignant syndrome was caused by antidopaminergic agents (5 antipsychotics, 1 metoclopramide) in 6 episodes and discontinuation of a dopaminergic agent, l -DOPA, in 12 episodes. In 1 patient, it was associated with simultaneous use of domperidone and amantadine withdrawal. Rigidity in NMS due to l -DOPA discontinuation was higher than in those due to antipsychotic use ( P = 0.027). Two of our patients needed intensive care, and 1 died.

CONCLUSIONS

This study highlights the high frequency of atypical NMS and the importance of early recognition of this potentially fatal syndrome, which can accompany neurodegenerative diseases and infections in older adults.

Management of a trauma patient with alcohol withdrawal who developed neuroleptic malignant syndrome in Korea: a case report

Neuroleptic malignant syndrome (NMS) is a rare but fatal condition, with a high mortality rate. NMS is characterized by altered mental status, fever, myoclonus, autonomic dysfunctions, and elevated creatinine phosphokinase. The clinical manifestations may be confused with alcohol-related symptoms, trauma, sepsis, postoperative agitation, or malignant hyperthermia. A 69-year-old male patient with alcohol withdrawal was admitted to the operating theatre to rule out septic shock due to mesenteric injury after multiple trauma. He was suspected NMS with abrupt increase body temperature to 41.7°C after haloperidol administration. Active cooling and rapid fluid infusion was done during anesthesia. Delayed diagnosis and treatment of NMS lead to catastrophic result. Therefore, if the patient's past medical history is unknown or clinical symptoms develop that are suggestive of NMS, early treatment must be considered.

COVID-19 Pandemic-Delayed Diagnosis and Treatment of Atypical Neuroleptic Malignant Syndrome in a Violent Forensics Patient With Intellectual Disability and Treatment-Resistant Schizophrenia

This case report highlights an episode of neuroleptic malignant syndrome (NMS) in a forensic psychiatry inpatient unit and how the coronavirus disease (COVID) pandemic, as well as, an atypical presentation of NMS delayed diagnosis and treatment of a patient, which could have been fatal. NMS and atypical NMS manifest typically after the use of anti-psychotics during the first two weeks of initiation of treatment. COVID can mimic many of the initial symptoms of NMS such as changes in mental status, fever, and, at times, dysautonomia. This case will try and highlight why this crossover of symptoms and the forensic environment made diagnosis and treatment in this particular case more difficult.

Serotonin Syndrome From Duloxetine Monotherapy: A Case Report

Serotonin syndrome is a rare adverse reaction induced by serotonergic drugs. Most instances of the syndrome occur in the context of a serotonergic drug overdose and the combined use of monoamine oxidase inhibitors and other related drugs. We report a case of serotonin syndrome caused by duloxetine alone in an elderly Asian woman and review the literature. A 69-year-old woman was admitted to the hospital due to two months of irritability and reduced energy. She was diagnosed with depressive disorder in the outpatient department and took sertraline 75mg for one month, but there was no significant improvement of symptoms. After admission, sertraline was switched to duloxetine. After taking duloxetine 60mg, the patient developed confusion, inducible clonus, diaphoresis, tremor, hyperreflexia, and increased body temperature and blood pressure. Reviewing her history of drug exposure, physical examination, and associated laboratory tests, we ruled out other possible diseases and established a serotonin syndrome diagnosis. The symptoms and signs associated with serotonin syndrome disappeared within two days after treatments with hydration and diazepam and the withdrawal of duloxetine. Physicians should be watchful for serotonin syndrome, a rare, but in severe cases life-threatening, adverse drug reaction. It may occur with duloxetine monotherapy even at therapeutic doses.

[Central anticholinergic, neuroleptic malignant and serotonin syndromes]

Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.

Going for a stroll on lurasidone: Considerations on an atypical case of acute compartment syndrome of both legs

Non-traumatic acute bilateral compartment syndrome is a rare condition that may lead to limb ischemia. We describe a case of this syndrome occurring after a five-kilometer walk in a young woman receiving chronic treatment with lurasidone, leading to a bilateral foot-drop and rhabdomyolysis of the anterolateral compartment of both legs. Due to her late presentation in the emergency department, we opted for a conservative approach, closely monitoring her renal function. We noticed a subsequent clinical and biochemical improvement over the following days, with the patient returning to her daily routine in a matter of weeks, despite a persisting bilateral foot drop. Since atypical antipsychotics are known to be associated with rhabdomyolysis, while possibly exerting a toxic effect on mitochondria, we hypothesize that a mild aerobic physical exertion might have triggered the event, in the context of an iatrogenic muscle susceptibility to oxidative distress.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.

The management challenges of a case with Flupentixol-induced neuroleptic malignant syndrome

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a rare and life-threatening reaction. The incidence rate of NMS has dropped because of the higher use of atypical antipsychotics, compared with the typical ones. The mortality rate in patients taking injectable antipsychotics has been also by 38%.

AIM

Here, a case developing the NMS symptoms following Flupentixol (FPX) use was reported.

CASE PRESENTATION

The patient was a 46-year-old man with the history of schizoaffective disorder (SAD) and recently on six-weekly doses of long-acting (LA) typical antipsychotic drugs. He was referred with a fever, sweating, a food intolerance, mutism, and disorientation in 2019. He was presented with generalized rigidity, negativism, and neck stiffness. The patient's initial creatine phosphokinase (CPK) level was 1476 IU/L, which gradually elevated to 3997 IU/L on Day 26. NMS was further diagnosed, in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, and the score 9+ in the Naranjo Algorithm as the adverse drug reaction probability scale. Afterward, the patient was treated with bromocriptine at a dose of 5 mg 3 times a day, which progressively reached a maximum of 50 mg. He experienced sepsis and resistant respiratory infection several times. The case was finally discharged after 66 days of hospitalization, with a high level of consciousness, but limited verbal communication, in a fever-free condition with the oral administration of bromocriptine and lorazepam.

CONCLUSION

In conclusion, there were suggestions for the management challenges of NMS in patients receiving LA injectable antipsychotic agents.

Eleven-Year Outcomes of Deep Brain Stimulation in Early-Stage Parkinson Disease

OBJECTIVE

The deep brain stimulation (DBS) in early-stage Parkinson's disease (PD) pilot clinical trial randomized 30 patients (Hoehn & Yahr II off; medication duration 0.5-4 years; without dyskinesia/motor fluctuations) to optimal drug therapy (ODT) (early ODT) or bilateral subthalamic nucleus (STN) DBS plus ODT (early DBS+ODT). This study aims to report the 11-year outcomes of patients who completed the DBS in early-stage PD pilot clinical trial.

MATERIALS AND METHODS

Attempts were made to contact all 29 subjects who completed the two-year trial to participate in an 11-year follow-up study. Mixed-effects models compared overall trend in outcomes for randomization groups (fixed-effects: assigned treatment, year, their interaction; random-effect: subject) to account for repeated measures.

RESULTS

Twelve subjects participated in this 11-year follow-up study (n = 8 early ODT, n = 4 early DBS+ODT). Participating subjects were 70.0 ± 4.8 years old with a PD medication duration of 13.7 ± 1.7 years (early DBS duration 11.5 ± 1.3 years, n = 4). Three early ODT subjects received STN-DBS as standard of care (DBS duration 6.5 ± 2.0 years). Early ODT subjects had worse motor complications (Unified Parkinson's Disease Rating Scale [UPDRS]-IV) than early DBS+ODT subjects over the 11-year follow-up period (between-group difference = 3.5 points; pinteraction = 0.03). Early DBS+ODT was well-tolerated after 11 years and showed comparable outcomes to early ODT for other UPDRS domains, Parkinson Disease Questionnaire-39 (PDQ-39), and levodopa equivalent daily dose (LEDD).

CONCLUSIONS

Eleven years after randomization, early DBS+ODT subjects had fewer motor complications than early ODT subjects. These results should be interpreted with caution because only 40% of pilot trial subjects participated in this 11-year follow-up study. The Food and Drug Administration has approved the conduct of a pivotal clinical trial evaluating DBS in early-stage PD (IDEG050016).

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT00282152.

[Central anticholinergic, neuroleptic malignant and serotonin syndromes : Important differential diagnoses in postoperative impairment of consciousness]

Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day^-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day^-1) is the recommended treatment.

Atypical Neuroleptic Malignant Syndrome in a COVID-19 Intensive Care Unit

Neuroleptic malignant syndrome (NMS) has been defined as a life-threatening neurologic emergency related to the use of antipsychotic medications. It is most often seen with high-potency (first-generation) antipsychotic medications and may occur after a single dose. There have been conflicting reports in the literature of an atypical NMS (ANMS) presentation, associated with lower-potency agents (second generation) antipsychotic medications. NMS is usually diagnosed with a tetrad of clinical symptoms although none of the tetrads is needed for diagnosis. We report a case of a patient admitted for severe acute syndrome coronavirus 2 (SARS-CoV2) pneumonia who developed probable ANMS. SARS-CoV2 also referred to as coronavirus disease 2019 (COVID-19) added another dimension of complication to patient care as we have, at this time, an incomplete understanding of the pathogenesis. We feel critical care clinicians should maintain broad differentials to clinical findings, during the use of multiple medications and not simply attribute the various presentations to COVID-19.

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 syndrome in a postoperative patient: A case report

Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis. A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity. Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms. The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.

A Rare Case of Drug Interaction Presenting as Perioperative Hyperthermia in a Patient Presenting for Neurosurgery

Perioperative hyperthermia has many differential diagnoses. This case report describes the rare causation of perioperative hyperthermia in a patient presenting for epilepsy surgery. The patient had two episodes of hyperthermia, initially post-anesthetic induction and later in the immediate post-operative period. The quest for the etiology sheds light on a rare drug interaction between topiramate, an antiepileptic drug, and glycopyrrolate causing intraoperative hyperthermia. However, the literature has not reported drug interaction between topiramate and glycopyrrolate resulting in perioperative hyperthermia. The combination of a glycopyrrolate-induced rise in temperature and oligohidrosis could have resulted in hyperthermia in our patient. Thus, it is prudent to avoid glycopyrrolate in the perioperative period when patients are on topiramate.

Exceptionally high creatine kinase levels in risperidone-induced neuroleptic malignant syndrome: A case report

Neuroleptic malignant syndrome is a rare, fatal antipsychotic-induced idiosyncratic reaction characterised by hyperthermia, altered consciousness, autonomic instability and rigidity with elevated creatine kinase levels and leukocytosis. Neuroleptic malignant syndrome and antipsychotics are significant causes for elevated creatine kinase among the extensive list of differential diagnoses. Risperidone is an atypical antipsychotic drug with anti-serotonergic and anti-dopaminergic properties which has a wide range of side effects, including neuroleptic malignant syndrome. Though the rise in creatine kinase in neuroleptic malignant syndrome is commonly around 2000 to 15,000 IU/L due to myonecrosis, ischaemia and heat production, normal creatine kinase levels in neuroleptic malignant syndrome were also reported. Up to now, only two cases have been reported with creatine kinase levels of more than 50,000 IU/L in neuroleptic malignant syndrome, but neither of them was risperidone-induced. We report the first case of an exceptional rise in creatine kinase levels more than 250-fold in a 16-year-old girl following low-dose risperidone-induced neuroleptic malignant syndrome.

Neuroleptic malignant syndrome in a postoperative patient: a case report

Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis. A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity. Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms. The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.

Atypical neuroleptic malignant syndrome and non-alcoholic Wernicke's encephalopathy

We report the case of a middle-aged woman with a history of bipolar disorder, in the absence of alcohol or substance misuse. The patient had been maintained on fluphenazine decanoate depot and now presented acutely with cognitive dysfunction and rigidity. Laboratory tests revealed elevated creatine kinase, acute kidney injury with metabolic acidosis and transaminitis, leading to a provisional diagnosis of neuroleptic malignant syndrome (NMS). Neuroleptics were withheld; dialysis was commenced; and blood biochemistry parameters improved in tandem. However, mental status changes persisted, and re-evaluation revealed multidirectional nystagmus with bilateral past-pointing. MRI confirmed the diagnosis of Wernicke's encephalopathy (WE). Prompt recovery followed treatment with high-dose intravenous thiamine. We discuss the co-occurrence of NMS and non-alcoholic WE-highlighting the need for a high index of suspicion for these relatively rare neuropsychiatric diagnoses which are often missed in those with atypical presentations.

Malignant syndromes: current advances

Introduction: Many drugs are known to induce malignant syndromes. The most common malignant syndromes are induced by the use of antipsychotics and anesthetics and the withdrawal of anti-Parkinson drugs. As the clinical manifestations of antipsychotic malignant syndrome, Parkinson's disease hyperpyrexia syndrome and anesthetic-induced malignant syndrome are very similar, they are easily confused in the clinic.Areas covered: We reviewed articles published between 1960 and April 2021 describing malignant syndromes. This paper provides a detailed literature review of malignant syndromes and important guidance for the diagnosis and treatment of malignant syndromes to clinicians.Expert opinion: Although malignant syndromes are rare conditions with a low incidence, these conditions usually progress rapidly and can endanger patients' lives, meriting attention from clinicians. The typical clinical manifestations of malignant syndromes are hyperpyrexia, muscular rigidity, an altered mental status and increased levels of creatine kinase; however, the pathophysiology, treatment and prognosis of different malignant syndromes are quite different. Prompt diagnosis and treatment may significantly improve the prognosis of patients with malignant syndromes.

Neuroleptic Malignant Syndrome: A Case of Unknown Causation and Unique Clinical Course

Neuroleptic malignant syndrome (NMS) is a rare, potentially lethal syndrome known to be related to the initiation of dopamine antagonist medications or rapid withdrawal of dopaminergic medications. It is a diagnosis of exclusion with a known sequela of symptoms, but not all patients experience these characteristic symptoms making it difficult at times to diagnose and treat. Herein, we present a unique case of NMS with unclear etiology and a unique clinical course. Our case report also raises the question of whether or not adjusting doses of previously prescribed neuroleptic medications can provoke NMS, providing valuable information for providers treating these complex patients. 

Case Report: Ziprasidone induced neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a well-recognized neurologic emergency. It presents with classic features including hyperthermia, autonomic instability, muscle hypertonia, and mental status changes. The syndrome is potentially fatal and is associated with significant morbidity due to complications such as rhabdomyolysis, acute kidney injury, and ventricular arrhythmias due to the trans-cellular electrolyte shift. NMS is conventionally associated with the first-generation antipsychotic agents, however, has been described with the use of atypical and novel antipsychotics including Ziprasidone. A case of NMS with Ziprasidone use at the therapeutic dose is reported here.

Atypical Neuroleptic Malignant Syndrome in the Setting of Quetiapine Overdose: A Case Report and Review of the Literature

Neuroleptic malignant syndrome (NMS) is a rare and life-threatening emergency. The condition is largely iatrogenic and is often precipitated by medications such as antipsychotics. First-generation antipsychotics are more likely to cause NMS than second-generation antipsychotics. The literature lacks an objective measure for NMS diagnosis. Instead, the diagnosis relies largely on the recognition of characteristic symptoms in the presence of an inciting medication. Additional challenges exist with concomitant disease processes and toxicities that may distort the clinical picture. Here, we report a case of a 44-year-old Caucasian man who presented with atypical NMS in the setting of quetiapine overdose. The patient remained uncharacteristically afebrile throughout his admission. Although the patient recovered, extended delays in identification and management can contribute to an increased risk of morbidity and mortality.

The neuroleptic malignant syndrome-a systematic case series analysis focusing on therapy regimes and outcome

INTRODUCTION

Neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening antipsychotic-associated disorder that requires an efficient and timely therapy. The aim of the study was to compare the effectiveness of different NMS therapies and to analyze its outcome depending on NMS severity.

METHOD

Systematic search for NMS cases in biomedical databases. The focus of the analysis was on therapy with dantrolene, bromocriptine, and electroconvulsive therapy (ECT) when each was compared with symptomatic therapy. Primary outcomes were the survival rate and the duration of treatment.

RESULT

405 case reports were included. Overall, no statistically significant differences regarding mortality rate or duration of treatment were found between dantrolene, bromocriptine, or ECT compared to supportive care. A subgroup analysis regarding NMS severity showed that the mortality under specific NMS pharmacotherapy (dantrolene, bromocriptine) and under ECT was significantly lower than under purely symptomatic therapy in severe NMS (P = 0.018). The difference was not significant in mild and moderate cases.

DISCUSSION

An overall superiority of the specific NMS therapy (dantrolene, bromocriptine, and ECT) was not found in this study. When regarding severity classification, specific therapies were superior but only in severe cases, and ECT showed the lowest mortality rate. In previous case series, an effect on survival or the duration of the disease could only be observed in part for specific therapies, but the evidence available is inconsistent. The results of this study support our hypothesis that NMS treatment with dantrolene, bromocriptine, and ECT is advantageous over purely symptomatic therapy in severe NMS cases.

How to use: creatine kinase

Creatine kinase (CK) remains an essential tool for assessment of muscular weakness and pain in children despite the advent of advanced diagnostic tests in this field. It is also useful in diagnosing and monitoring various other conditions. This article will explore the physiology of CK and clinical situations where the estimation of CK can help the clinicians' decision-making process with the diagnosis and management of these conditions. Some clinical scenarios are used to highlight how the tests can be used in different clinical situations. The role of CK as a biomarker of myocardial injury has been purposefully omitted in this article.

Coexistence of guanidinoacetate methyltransferase (GAMT) deficiency and neuroleptic malignant syndrome without creatine kinase elevation

We describe the first child with guanidinoacetate methyltransferase (GAMT) deficiency who developed neuroleptic malignant syndrome (NMS) after the treatment of risperidone without elevated creatine kinase (CK) levels. The patient presented with lethargy, hyperthermia, generalized tremor and rigidity with normal serum CK levels. After cessation of risperidone and adding clonezepam to the supportive treatment, symptoms of NMS were ameliorated. We conclude that although serum CK elevation is a useful indicator for the early detection of NMS, normal serum CK levels may be seen during the NMS course in the presence of GAMT deficiency.

Rhabdomyolysis associated acute renal failure - Report of two fatal cases and a brief review of literature

BACKGROUND

Rhabdomyolysis is a potentially fatal condition which occurs due to skeletal muscle injury and classically presents with myalgia and red-brown coloured urine. Presence of excess myoglobin in the glomerular filtrate forms myoglobin casts which causes severe obstruction and necrosis of the tubules leading to acute renal failure.

METHODS

We report two fatal cases of rhabdomyolysis associated acute renal failure. The first victim died in police custody and the second victim died due to severe physical exertion.

RESULTS

In both the cases, creatine kinase levels were elevated and myoglobin was detected in urine in the second case. Myoglobin immunohistochemistry detected the presence of myoglobin cast in the glomerular tubules of kidney in both the cases.

CONCLUSIONS

Myoglobin immunohistochemistry of renal tissues, serum creatine kinase, urine myoglobin analysis and muscle histopathology are the laboratory tests that should be considered at autopsy where rhabdomyolysis is suspected.

Neuroleptic malignant syndrome: a concealed diagnosis with multitreatment approach

While neuroleptic malignant syndrome (NMS) is typically characterised by delirium, motor rigidity, fever and dysautonomia, the syndrome is not pathognomonic, and NMS remains a diagnosis of exclusion. Here, we describe the case of a 44-year-old woman, with no relevant psychiatric history, admitted to a nephrology unit due to acute renal failure. After administration of antipsychotics, she presented with mental status alteration, generalised tremor, rigidity and autonomic nervous system dysfunction. Fever and rhabdomyolysis, however, were not prominent, and NMS was not considered initially in the differential diagnosis. The resulting delay in diagnosis, with continued administration of antipsychotics, led to progressive clinical deterioration. Once NMS was considered, however, antipsychotics were withdrawn and the patient was treated with electroconvulsive therapy (ECT), followed by administration of a dopamine receptor agonist, with close to full remission of all symptoms. Importantly, during outpatient follow-up, sustained mild and asymmetric tremor and rigidity was noted, leading to a diagnosis of Parkinson's disease. While this raises questions regarding differential diagnosis between NMS in Parkinson's disease, versus worsening of Parkinson's disease due to antipsychotic treatment, the former is supported by the acute and rapidly progressive onset of exuberant autonomic dysfunction and clouded conscience, after administration of a neuroleptic. Ultimately, a definitive distinction between these two alternatives for diagnosis of the inaugural neurological presentation in this patient is not possible. Nevertheless, we believe this case illustrates that NMS can be easily missed, particularly in atypical cases, delaying appropriate treatment, and that a flexible multimodal treatment approach, involving ECT, should be considered for complex clinical cases. Furthermore, it also underlines the importance of post-NMS follow-up, to investigate underlying neurological or medical disorders, particularly in those patients who do not have a full recovery.

An Approach to the Pharmacotherapy of Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome is a rare, idiosyncratic emergency associated with exposure to dopamine antagonists, commonly antipsychotic drugs. The typical clinical picture consists of altered consciousness, muscular rigidity, fever, and autonomic instability. While the condition has generally been well described, the pathophysiology is still poorly understood. The importance of this case report is to highlight the lack of robust evidence-based treatment for this emergency. We submit an approach to the pharmacotherapy of neuroleptic malignant syndrome based on the available evidence.

Serotonin Syndrome and the Anaesthetist

Serotonin syndrome results from excessive activation of serotonin (5-hydroxytryptamine; 5-HT) receptors in the nervous system, on the surface of platelets, and on the vascular endothelium. The clinical manifestations are a triad of altered conscious state, autonomic dysfunction, and neuromuscular excitability. Clinical diagnostic criteria remain poorly defined and unvalidated, and there are no available investigations to confirm the diagnosis. The syndrome is caused by the administration of one or more drugs possessing serotonergic activity. Severe forms of the syndrome usually result from overdose, but can be induced by monotherapy. The exact incidence of serotonin syndrome remains unknown, but is likely to be increasing due to increased prescription of selective serotonin reuptake inhibitor anti-depressants and tramadol, as well as recreational use of amphetamine-like substances. Serotonin syndrome may complicate the administration of drugs frequently used in anaesthetic practice, including pethidine and tramadol. Although the majority of cases improve with symptomatic and supportive care, severe cases need intensive care and frequently require mechanical ventilation. Neuromuscular excitability is likely to be the cause of rhabdomyolysis seen in severe cases and should be treated with benzodiazepines and muscle relaxants. Supportive therapies are required to treat hyperthermia and autonomic dysfunction. Cyproheptadine is the most commonly administered serotonergic antagonist, but is unavailable in parenteral form.

Neuroleptic malignant-like syndrome causing thrombocytopaenia: a rare association

Neuroleptic malignant-like syndrome is a rare but potentially fatal complication of sudden withdrawal of dopaminergic drugs. Clinical features are similar to that of neuroleptic malignant syndrome (NMS) like hyperthermia, autonomic dysfunction, altered sensorium, muscle rigidity; but instead of history of neuroleptic use, there is history of withdrawal of dopaminergic drugs. Laboratory examination generally show elevated creatine phosphokinase levels and may show elevated total leucocyte count. Thrombocytopaenia has been very rarely reported with NMS but it has not been reported with NM-like syndrome. Here, we discuss a case of Parkinson's disease which presented with typical clinical features and risk factors of NM-like syndrome associated with thrombocytopaenia and type 1 respiratory failure. He was treated with bromocriptine and supportive care. Thrombocytopaenia and respiratory failure resolved with above treatment. The patient improved clinically and was successfully discharged on day 12 of admission.

Consideration of Occult Infection and Sepsis Mimics in the Sick Patient Without an Apparent Infectious Source

BACKGROUND

Evaluation and treatment of the acutely ill patient is typically complicated by multiple comorbidities and incomplete medical histories. This is exemplified by patients with sepsis, whose care is complicated by variable presentations, shifting definitions, and a variety of potential sources. Many practitioners fail to consider and recognize less-common sources of infection in a timely manner. Additionally, multiple noninfectious conditions can present with the fever and tachycardia typical of the septic patient. The errors of anchoring and premature closure may lead to delay in, or failure of, diagnosis of these conditions.

OBJECTIVE

This review addresses the evaluation of the acutely ill-appearing patient without an apparent source, focusing on occult sources of infection and conditions that mimic sepsis.

DISCUSSION

Musculoskeletal, cardiac, neuraxial, and abdominal sources of sepsis should be considered in the acutely ill patient. Indwelling devices should be carefully examined for signs of infection. Consideration for sepsis mimics, such as neuroleptic malignant syndrome, malignant hyperthermia, medication toxicity, and thyroid storm, in patients who fail to respond to standard therapies for sepsis, may lead the physician to potentially reversible life-threatening diagnoses and management.

CONCLUSION

In the seemingly septic patient who does not respond to antimicrobials and fluids, the differential should be broadened to include acutely life-threatening conditions that can mimic sepsis. A review of the patient's medical history, medications, and recent exposures can assist in identifying the source of the patient's elevated body temperature and tachycardia. Consideration of potential sources and other mimics of sepsis is needed in the emergency department.

Neuroleptic malignant syndrome in a young adult female at the university of Benin Teaching Hospital: a case report

Background

Neuroleptic malignant syndrome is a rare but life-threatening idiosyncratic complication following the use of antipsychotic agents, anaesthesia and surgery. It is characterized by hyperthermia, muscle rigidity, autonomic disturbances and mental state alterations.

Case

A 31 year old female weighing 60kg received a depot preparation of Fluphenazine on account of depression with psychotic features observed two days prior to elective Cholecystectomy under general anaesthesia. Surgery and anaesthesia were essentially uneventful. Forty eight hours post-operatively, the patient developed features suggestive of neuroleptic malignant syndrome complicated by aspiration pneumonitis. This necessitated her admission into the intensive care unit. She had prolonged stay in the intensive care unit, where she was mechanically ventilated, developed deep venous thrombosis of the left upper limb and required tracheostomy on account of prolonged endotracheal intubation. Patient recovered fully following bromocriptine and dantrolene therapy. She was discharged home after 60 days on admission and has remained in good health.

Conclusion

Though rare, neuroleptic malignant syndrome can occur in young adult females following use of antipsychotics, anaesthesia and surgery. Its clinical course can be prolonged and distressing with the use of depot preparations. Early diagnosis and prompt supportive measures are essential to reduce morbidity and mortality.

Possible Biological Mechanisms Linking Mental Health and Heat-A Contemplative Review

This review provides examples of possible biological mechanisms that could, at least partly, explain the existing epidemiological evidence of heatwave-related exacerbation of mental disease morbidity. The author reviews the complicated central processes involved in the challenge of maintaining a stable body temperature in hot environments, and the maladaptive effects of certain psychiatric medicines on thermoregulation. In addition, the author discusses some alternative mechanisms, such as interrupted functional brain connectivity and the effect of disrupted sleep, which may further increase the vulnerability of mental health patients during heatwaves.

Early detection of an atypical presentation of neuroleptic malignant syndrome: A case report

Neuroleptic malignant syndrome (NMS), which is considered a neurologic emergency, is believed to be caused by exposure to dopamine antagonist or withdrawal from a dopamine agonist. This article reports a case of suspected atypical NMS in a patient following rapid conversion of ziprasidone to risperidone without titration. While the initial presentation did not fully meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, diagnostic features, a sequential treatment strategy was initiated and the patient appropriately responded to antipsychotic cessation in addition to combination therapy with dantrolene and bromocriptine. Neuroleptic malignant syndrome diagnostic criteria, treatment, and prognosis are discussed.

A retrospective analysis of cases with neuroleptic malignant syndrome and an evaluation of risk factors for mortality

Objective

Neuroleptic malignant syndrome (NMS) is a neurological emergency rarely encountered in clinical practice but with a high mortality rate. Cases associated with atypical antipsychotic use or termination of dopamine agonists have been seen in recent years. The purpose of this study was to assess the presence of risk factors for mortality by investigating all clinical and laboratory characteristics of cases with NMS.

Material and methods

This descriptive, cross-sectional study retrospectively investigated all clinical and laboratory characteristics by scanning the ICD-10 codes of patients presenting to the XXXX Faculty of Medicine Emergency Department and diagnosed with NMS between 2006 and 2016. Patients were divided into surviving and non-surviving groups, and the data elicited were subjected to statistical comparisons.

Results

The mean age of the 18 patients diagnosed with NMS was 46.9 ± 4.8 years, and 50% were women. In addition to antipsychotics among the drugs leading to NMS, the syndrome also developed as a result of levodopa withdrawal in three patients and metoclopramide use in one patient. Statistically significant differences were determined between the surviving and non-surviving patients in terms of blood pressure, blood urea nitrogen (BUN), creatine kinase (CK) and mean platelet volume (MPV) values (p ≤ 0.05).

Conclusion

In this study the most common agent that cause NMS was atypical antipsychotics. Also advanced age, increased blood pressure and serum CK, BUN and MPV values were identified as potential risk factors for mortality in NMS.

Neuroleptic malignant syndrome with thyroid disorder: An unusual case report

RATIONALE

Neuroleptic malignant syndrome (NMS) is a life threatening neurologic emergency associated with neuroleptic or antipsychotic agent use. NMS is rarely related to thyroid disease.

PATIENT CONCERNS

We report a case of NMS in a 66-year-old male with past medical history of paranoid schizophrenia on chlorpromazine, diabetes, hypertension and asthma, who presented with a humeral fracture after a fall. Patient developed hyperpyrexia, altered consciousness, autonomic instability, elevated serum creatine kinase (CK) without rigidity.

DIAGNOSES

CT head and workup for infection were negative. Electroencephalogram (EEG) showed generalized slow wave activity. Ultrasound revealed a large goiter with nodules.

INTERVENTIONS

Chlorpromazine was stopped due to concern of NMS. Patient was treated with cooling, fluid and electrolyte maintenance.

OUTCOMES

Patient slowly improved and CK level normalized. Thyroid-stimulating hormone (TSH) level trended down from 10.2 mIU/L to 0.02 mIU/L. Patient was discharged with aripiprazole.

LESSONS

Hypothyroidism predisposes patients to NMS by altering central dopaminergic systems. The typical symptoms may be masked by hypothyroidism. Thyroid dysfunction should be excluded in all patients with NMS. Discontinuing antipsychotic agents decreases TSH levels which maybe due to the negative feedback of dopaminergic activity. This is the first case report describing dramatic changes in TSH after discontinuing chlorpromazine in NMS.

Neuroleptic Malignant Syndrome with Minimal Dose of Amisulpride

Amisulpride is an atypical antipsychotic drug, it helps in alleviation of symptoms of psychotic illnesses. Extrapyramidal features have been reported after taking amisulpride. Neuroleptic malignant syndrome (NMS) with amisulpride is rare, and have been reported earlier. In all the earlier reported cases patient received more than 150 mg of amisulpride. To the best of our knowledge we are reporting a case of NMS with very minimal dose of Amisulpride (50 mg) taken for very short period.