Efficacy of methylprednisolone pulse therapy on neuroleptic malignant syndrome in Parkinson's disease

A Rare Case of Malignant Syndrome in Parkinson's Disease Caused by Severe Dehydration and Complicated by Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

Malignant syndrome (MS) in Parkinson's disease (PD) is a rare complication that occurs in patients who have a history of PD and are taking dopaminergic drugs. The syndrome is quite similar to neuroleptic malignant syndrome (NMS) in presentation and is a potentially fatal syndrome. Awareness of symptoms, early diagnosis, and the ability to differentiate it from NMS is important to prevent mortality. Clinical manifestations of MS are similar to NMS and include altered mentation, rigidity, fever, leukocytosis, and elevated serum creatine kinase (CK). However, MS is differentiated from NMS by the precipitating factors; of which, the commonest precipitating factor for MS is dopaminergic drug withdrawal or dose reduction while other less common causes include infection, dehydration, and hot weather. We present a rare case of MS in a patient with a history of PD precipitated by severe dehydration and hot weather in the absence of dopaminergic drug withdrawal. He presented with fever, severe rigidity, altered mentation, dehydration, leukocytosis, and elevated CK. He was correctly diagnosed with MS and promptly treated, preventing mortality. The triad of fever, severe rigidity, and altered sensorium in a patient with a history of PD should prompt evaluation for MS in addition to NMS to initiate appropriate treatment and prevent mortality.

An unwell patient with Parkinson's disease: Hyperpyrexia syndrome in a heatwave

Hyperpyrexia syndrome in Parkinson's disease (PD) is a medical emergency requiring prompt action. This can be precipitated by numerous provoking factors, in particular withdrawal of dopaminergic medication.

We report a case of a patient with PD presenting with confusion, dramatic worsening of PD symptoms and pyrexia in the context of a heatwave, potentially mediating its effect through dehydration and impaired medication absorption. Precipitous cooling and conversion of dopaminergic medication to a rotigotine patch due to drowsiness led to her rapid improvement. The possibility of infection was covered however no source of infection or evidence of inflammatory response was found, but remained an important differential.

This case highlights the importance of recognising and managing hyperpyrexia syndrome in PD and the possibility of uncharacteristically hot weather being a cause.

Toxicology of Psychoactive Substances

A trend in the increasing use of prescription psychoactive drugs (PADs), including antidepressants, antipsychotics, and mood stabilizers, has been reported in the United States and globally. In addition, there has been an increase in the production and usage of illicit PADs and emergence of new psychoactive substances (NPSs) all over the world. PADs pose unique challenges for critical care providers who may encounter toxicology issues due to drug interactions, side effects, or drug overdoses. This article provides a summary of the toxicologic features of commonly used and abused PADs: antidepressants, antipsychotics, mood stabilizers, hallucinogens, NPSs, caffeine, nicotine, and cannabis.

The safety of pulse corticosteroid therapy- Systematic review and meta-analysis

OBJECTIVE

To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety.

PATIENTS AND METHODS

All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality.

RESULTS

A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids.

CONCLUSION

Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.

Risk Factor Analysis for the Outcomes of Indirect Traumatic Optic Neuropathy with No Light Perception at Initial Visual Acuity Testing

BACKGROUND

The optimal management of indirect traumatic optic neuropathy (TON) is controversial. We aimed to compare the differences in visual improvement by treatment option in patients presenting with TON and no light perception (NLP). We also wanted to identify any patient-related factors that might favor the use of steroid pulse therapy or optic nerve decompression (OND).

METHODS

We retrospectively identified 46 consecutive patients with indirect TON treated at Chang Gung Memorial Hospital between 2007 and 2015. The outcome was the improvement in visual acuity by improvement rate and degree of improvement.

RESULTS

Females had a better improvement rate than did males. Compared with delayed treatment, patients receiving steroid pulse therapy within 14 hours or receiving OND within 26 hours had a better improvement rate/degree. In patients with an initial intraocular pressure (IOP) of 17-23 mm Hg, the improvement rate/degree was significantly better than for patients with an IOP outside this range. For patients treated by OND, an initially normal IOP (11-21 mm Hg) suggested a significantly better prognosis in the improvement rate/degree.

CONCLUSIONS

For patients with indirect TON, initial NLP implies a poor prognosis, but steroid pulse therapy or OND are both feasible treatment options. These results emphasize the importance of timely treatment for patients with indirect TON and NLP. Females and patients with an initial IOP of 17-23 mm Hg were more likely to recover. The results of our study indicate that normal initial IOP (11-21 mm Hg) is good prognostic factor for patients with indirect TON treated with OND.

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.

Neuroleptic malignant syndrome as a presenting feature of subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a slowly progressive degenerative disorder caused by measles virus. It is characterised by typical clinical and electrophysiological features in the form of slow myoclonic jerks, with progressive cognitive impairment, visual symptoms, and periodic complexes on EEG, with raised titres of anti-measles antibodies in CSF and serum. Atypical presentations of SSPE have been reported including brainstem involvement, ADEM-like presentation, acute encephalitis, and cerebellar ataxia. Presentation with predominant extrapyramidal features is uncommon. We describe a case of SSPE presenting with extensive rigidity with highly elevated CPK values, mimicking neuroleptic malignant syndrome (NMS) which was most probably due to central dopaminergic blockade induced by the disease process. To our knowledge, this is the first case of SSPE presenting with a NMS-like syndrome.

Acute Presentation of Nonmotor Symptoms in Parkinson's Disease

There are a few syndromes involving the nonmotor symptoms of Parkinson's disease and other movement disorders that can quickly lead to severe morbidity and mortality, and, as such, need rapid identification and management. Among these are neuroleptic malignant syndrome, serotonin syndrome, dopamine agonist withdrawal syndrome, and dystonic storm. It is important to maintain a high index of suspicion for these disorders as lack of identification can lead to death. Many of these acutely occurring nonmotor syndromes are primarily the result of imbalances in dopaminergic and serotonergic systems due to changes in pharmacologic management of psychiatric disorders or Parkinson's disease. We discuss these acutely occurring nonmotor symptoms in order to raise awareness and also to highlight how these extremes in symptoms may uniquely shed light on the pathophysiology of Parkinson's disease.

Risk Factors Analysis for the Outcome of Indirect Traumatic Optic Neuropathy With Steroid Pulse Therapy

BACKGROUND

Although recent evidence suggests a controversy effect of steroids in the management of indirect traumatic optic neuropathy (TON), steroid pulse therapy remains one of the reasonable treatments for patients with indirect TON. It is thought that microcirculatory spasms, edema, and nerve cell necrosis can be prevented or reduced by large doses of steroids. The aim of this study is to analyze the predisposing factors for the recovery of patients with indirect TON who were treated with steroid pulse therapy.

MATERIALS AND METHODS

In tracing the 2008 to 2014 data from the Trauma Center of Chang Gung Memorial Hospital, 20 consecutive cases of indirect TON were identified retrospectively. Twenty cases showed no light perception (NLP) under initial ophthalmologic examination. They all received steroid pulse therapy with methylprednisolone in IV form after examination by ophthalmologists, and they did not receive optic nerve decompression. The general data, fracture pattern from images, hospital courses, trauma-related data from ER record, and the initial and final visual data from ophthalmologic records are reviewed. The odds ratio (OR) and 95% confidence intervals (CI) are calculated. Fisher exact test is used for 2 variables to test differences between proportions. Nonparametric statistics are applied to compare the mean values of the data.

RESULTS

The results show that for female patients (OR, 3.400; 95% CI, 1.628-7.101; P = 0.049), the administration of methylprednisolone in less than 24 hours from the injury (OR, 3.429; 0.297-39.637), lateral force fracture pattern (OR, 3.500; 0.313-39.153), age of 40 years or younger (OR, 2.333; 0.197-27.567), and pure facial trauma (OR, 3.667; 0.273-49.288) are the predisposing factors for improvement of visual acuity. Patients with orbital blowout fractures (OR, 9.800; 95% CI, 0.899-106.845; P = 0.070), initial free extraocular movement (EOM) (OR, 6.667; 0.809-54.597; P = 0.145), initial intraoptic pressure (IOP) greater than 25 mmHg (OR, 8.000; 0.598-106.936), and higher triage grade (OR, 3.000; 0.447-20.153) are at risk of showing no improvement.

CONCLUSIONS

From this study, we might suggest to apply steroid pulse therapy on those patients without contraindication, with an incurring injury less than 24 hours previously. Factors such as sex, age, lateral force fracture pattern, and pure facial trauma revealed a better outcome for improvement of visual acuity. Orbital blowout fractures, initial free EOM, initial IOP greater than 25 mmHg, and higher triage grade suggested poor improvement of visual acuity.

Critical Illness Neuromyopathy Complicating Akinetic Crisis in Parkinsonism: Report of 3 Cases

Akinetic crisis (AC) is a life-threatening complication of parkinsonism characterized by an acute severe akinetic-hypertonic state, consciousness disturbance, hyperthermia, and muscle enzymes elevation. Injectable dopaminomimetic drugs, high-dose methylprednisolone, and dantrolene are advocated as putative specific treatments. The course of the illness is frequently complicated by infections, pulmonary embolism, renal failure, disseminated intravascular coagulation, and cardiac arrhythmias. Critical illness neuromyopathy (CINM) is an acquired neuromuscular disorder characterized by flaccid quadriparesis and muscle enzyme elevation, often occurring in intensive care units and primarily associated with inactivity, sepsis, multiorgan failure, neuromuscular blocking agents, and steroid treatment. In 3 parkinsonian patients, during the course of AC we observed disappearance of rigidity but persistent hypoactivity. In all, neurological examination showed quadriparesis with loss of tendon reflexes and laboratory investigation disclosed a second peak of muscle enzymes elevation, following the first increment due to AC. Electrophysiological studies showed absent or reduced sensory nerve action potentials and compound muscular action potentials, myopathic changes, and fibrillation potentials at electromyography recordings, and reduced excitability or inexcitability of tibialis anterior at direct muscle stimulation, leading to a diagnosis of CINM in all 3 patients. In 1 patient, the diagnosis was also confirmed by muscle biopsy. Outcome was fatal in 2 of the 3 patients. Although AC is associated with most of the known risk factors for CINM, the cooccurrence of the 2 disorders may be difficult to recognize and has never been reported. We found that CINM can occur as a severe complication of AC, and should be suspected when hypertonia-rigidity subsides despite persistent akinesia. Strict monitoring of muscle enzyme levels may help diagnosis. This finding addresses possible caveats in the use of putative treatments for AC.

Glucocorticoid-induced leucine zipper (GILZ) controls inflammation and tissue damage after spinal cord injury

AIMS

Spinal cord injury (SCI) occurs following damage to the spinal column. Following trauma, tissue damage is further exacerbated by a secondary damage due to a SCI-activated inflammatory process. Control of leukocytes activity is essential to therapeutic inhibition of the spinal cord damage to ameliorate the patient's conditions. The mechanisms that regulate neuroinflammation following SCI, including T-cell infiltration, have not been completely clarified. Glucocorticoids (GC) are antiinflammatory drugs widely used in therapy, including treatment of SCI. GC efficacy may be linked to many molecular mechanisms that are involved in regulation of leukocytes migration, activation, and differentiation. We have previously shown that the antiinflammatory activity of GC is in part mediated by glucocorticoid-induced leucine zipper (GILZ). Here, we investigated the role of GILZ in inflammation and spinal cord tissue damage following a spinal trauma.

METHODS

We address the role of GILZ in SCI-induced inflammation and tissue damage using a model of SCI in gilz knockout (gilz KO) and wild-type (WT) mice.

RESULTS

We found that GILZ deficiency is associated with a strong reduction of SCI-induced inflammation and a significantly reduced lesion area following SCI.

CONCLUSION

These results demonstrate that GILZ is involved in induction of neuroinflammation and functional outcomes of spinal cord trauma.

Treatment of movement disorder emergencies

Movement disorder emergencies are defined as clinical scenarios where a movement disorder develops over hours to days, and in which morbidity and even mortality can result from failure to appropriately diagnose and manage the patient. The last decade has seen increasing recognition of various movement disorder emergencies, including acute parkinsonism, neuroleptic malignant syndrome, respiratory compromise in multiple system atrophy, dystonic storm, oculogyric crisis, and hemiballism, among others. This article will review the major movement disorder emergencies encountered in the hospital and office, emphasizing practical management and treatment.

Malignant syndrome in Parkinson's disease without dopaminergic drug withdrawal

Malignant syndrome is a rare complication occurring during the course of drug treatment for Parkinson's disease. It resembles neuroleptic malignant syndrome and is characterized by fever, marked rigidity, altered consciousness, leucocytosis and elevated creatine kinase. Malignant syndrome is a potentially fatal condition and awareness of this condition is imperative for prevention and treatment. The commonest precipitating factor is dopaminergic drug withdrawal or dose reduction. We report malignant syndrome (precipitated by hyponatremia) in a case of Parkinson's disease, in the absence of dopaminergic drug withdrawal. A 60-year-old man presented with fever, severe rigidity and altered sensorium following repeated vomiting. On investigation, he was found to have hyponatremia precipitated malignant syndrome. Treatment with hydration, cooling, correction of hyponatremia and dopaminergic drugs reversed his condition. The triad of fever, severe rigidity and altered sensorium should prompt evaluation for malignant syndrome in Parkinson's disease.

Movement disorder emergencies

Movement disorder emergencies include any movement disorder which evolves over hours to days, in which failure to appropriately diagnose and manage can result in patient morbidity or mortality. It is crucial that doctors recognize these emergencies with accuracy and speed by obtaining the proper history and by being familiar with the phenomenology of frequently encountered movements. These disorders will be discussed based on the most common associated involuntary movement, either parkinsonism, dystonia, chorea, tics or myoclonus, and, when available, review the workup and treatment options based on the current literature.

It was not just a heatwave! Neuroleptic malignant-like syndrome in a patient with Parkinson's disease

Neuroleptic malignant-like syndrome (NMLS) is a rare but life threatening and important complication because of the withdrawal of long-term l-Dopa therapy in Parkinson's disease patients. In this case report, we review the pathophysiology, clinical features and treatment of this curable condition.

Parkinsonism–hyperpyrexia syndrome: The role of electroconvulsive therapy

Herein, we present a case of a parkinsonism-hyperpyrexia syndrome (PHS) in a 58-year-old man with a 10-year history of Parkinson's disease. The patient presented with a 2-week history of fever and increasing confusion, in the context of a number of changes to his medication regimen. On presentation, he was noted to be febrile with autonomic instability, diaphoresis and marked rigidity. He was disoriented and responding to visual hallucinations. Investigations revealed an elevated creatine kinase and a provisional diagnosis of PHS was made. After the patient failed to respond during a 2-week period to supportive measures, electroconvulsive therapy (ECT) treatment was commenced. A good response to eight bilateral ECT treatments was achieved, with resolution of his confusional state and associated psychotic phenomena. We discuss the nosological and management issues associated with this case and discuss the role of ECT as a treatment modality in this condition.

Hyperthermic Syndromes Induced by Toxins

Normal thermogenesis requires a complex interaction between systems that generate and dissipate heat. Serving as director of thermogenesis, the hypothalamus activates the sympathetic nervous system along with the thyroid and adrenal glands to respond to changes in body temperature. Working in concert, these systems result in heat generation by uncoupling of oxidative phosphorylation, combined with impaired heat dissipation through vasoconstriction. In this article, the authors discuss serotonin and sympathomimetic syndromes, neuroleptic malignant syndrome,and malignant hyperthermia and how these syndromes affect the hypothalamic and sympathetic nervous systems, resulting at times in severe hyperthermia. Current treatment recommendations and future trends in treatment are also discussed.

Toxin-induced hyperthermic syndromes

Toxin-induced hyperthermic syndromes are important to consider in the differential diagnosis of patients presenting with fever and muscle rigidity. If untreated, toxin-induced hyperthermia may result in fatal hyperthermia with multisystem organ failure. All of these syndromes have at their center the disruption of normal thermogenic mechanisms, resulting in the activation of the hypothalamus and sympathetic nervous systems.The result of this thermogenic dysregulation is excess heat generation combined with impaired heat dissipation. Although many similarities exist among the clinical presentations and pathophysiologies of toxin-induced hyperthermic syndromes, important differences exist among their triggers and treatments. Serotonin syndrome typically occurs within hours of the addition ofa new serotonergic agent or the abuse of stimulants such as MDMA or methamphetamine. Treatment involves discontinuing the offending agent and administering either a central serotonergic antagonist, such as cyproheptadine or chlorpromazine, a benzodiazepine, or a combination of the two. NMS typically occurs over hours to days in a patient taking a neuroleptic agent; its recommended treatment is generally the combination of a central dopamine agonist, bromocriptine or L-dopa, and dantrolene. In those patients in whom it is difficult to differentiate between serotonin and neuroleptic malignant syndromes, the physical examination may be helpful:clonus and hyperreflexia are more suggestive of serotonin syndrome,whereas lead-pipe rigidity is suggestive of NMS. In patients in whom serotonin syndrome and NMS cannot be differentiated, benzodiazepines represent the safest therapeutic option. MH presents rapidly with jaw rigidity, hyperthermia, and hypercarbia. Although it almost always occurs in the setting of surgical anesthesia, cases have occurred in susceptible individuals during exertion. The treatment of MH involves the use of dantrolene. Future improvements in understanding the pathophysiology and clinical presentations of these syndromes will undoubtedly result in earlier recognition and better treatment strategies.

Movement disorder emergencies

For the past 4 years, Dr. Stanley Fahn and I have given a course at the American Academy of Neurology annual meeting on the topic of movement disorder emergencies. The purpose of this review article is to summarize the topic and to present it to readers of this journal. The text of this article has appeared in nearly the same form as the Academy syllabus accompanying our course. It is being presented here so that readers of the journal may review the material.

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.

Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians

Rhabdomyolysis ranges from an asymptomatic illness with elevation in the creatine kinase level to a life-threatening condition associated with extreme elevations in creatine kinase, electrolyte imbalances, acute renal failure and disseminated intravascular coagulation. Muscular trauma is the most common cause of rhabdomyolysis. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, drugs, toxins and endocrinopathies. Weakness, myalgia and tea-colored urine are the main clinical manifestations. The most sensitive laboratory finding of muscle injury is an elevated plasma creatine kinase level. The management of patients with rhabdomyolysis includes early vigorous hydration.