Novel antipsychotics and the neuroleptic malignant syndrome: a review and critique

Neuroleptic malignant syndrome and serotonin syndrome: a comparative bibliometric analysis

OBJECTIVE

This study aimed to analyze and map scientific literature on Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) from prestigious, internationally indexed journals. The objective was to identify key topics, impactful articles, prominent journals, research output, growth patterns, hotspots, and leading countries in the field, providing valuable insights for scholars, medical students, and international funding agencies.

METHODS

A systematic search strategy was implemented in the PubMed MeSH database using specific keywords for NMS and SS. The search was conducted in the Scopus database, renowned for its extensive coverage of scholarly publications. Inclusion criteria comprised articles published from 1950 to December 31st, 2022, restricted to journal research and review articles written in English. Data were analyzed using Microsoft Excel for descriptive analysis, and VOSviewer was employed for bibliometric mapping.

RESULTS

The search yielded 1150 articles on NMS and 587 on SS, with the majority being case reports. Growth patterns revealed a surge in NMS research between 1981 and 1991, while SS research increased notably between 1993 and 1997. Active countries and journals differed between NMS and SS, with psychiatry journals predominating for NMS and pharmacology/toxicology journals for SS. Authorship analysis indicated higher multi-authored articles for NMS. Top impactful articles focused on review articles and pathogenic mechanisms. Research hotspots included antipsychotics and catatonia for NMS, while SS highlighted drug interactions and specific medications like linezolid and tramadol.

CONCLUSIONS

NMS and SS represent rare but life-threatening conditions, requiring detailed clinical and scientific understanding. Differential diagnosis and management necessitate caution in prescribing medications affecting central serotonin or dopamine systems, with awareness of potential drug interactions. International diagnostic tools and genetic screening tests may aid in safe diagnosis and prevention. Reporting rare cases and utilizing bibliometric analysis enhance knowledge dissemination and research exploration in the field of rare drug-induced medical conditions.

Neuroleptic malignant syndrome in patients with cancer: a systematic review

BACKGROUND

Antipsychotics potentially cause a low incidence of the side effect called neuroleptic malignant syndrome (NMS), which has a high mortality rate. However, few studies on NMS among patients with cancer exist.

AIMS

We aimed to examine the characteristics of antipsychotic-induced NMS among patients with cancer.

METHODS

We conducted a systematic review of published reports on NMS described during the treatment of patients with any type of cancer. Articles were identified by a comprehensive search of PubMed, Web of Science, the Cochrane Library and reference lists from relevant articles published until 25 December 2019. Original articles or case reports on humans published in English were included. This review summarises the symptoms, characteristics, treatment course and prognosis of patients with cancer with NMS.

RESULTS

Eleven patients with various cancer types from ten case reports published from 1988 to 2013 met the eligibility criteria. Mean age of the 11 patients was 52.5 (range, 32-83) years. NMS developed mostly during the postoperative period, and haloperidol and D2 receptor antagonists were determined as the common causative drugs. Ten patients survived following treatment that mostly involved discontinuing the causative drugs and administering dantrolene, if necessary.

CONCLUSION

Although NMS intrinsically has a low incidence and high mortality, only few reports were available, with most patients surviving after early detection and appropriate treatment. Healthcare providers should consider NMS development while prescribing antipsychotics to ensure prompt recognition of the condition and rapid treatment for preventing unnecessary deaths.

The use of atypical antipsychotics in the treatment of catatonia

Purpose

Evidence indicates that classical antipsychotics may aggravate non-malignant and malignant catatonia (MC). Atypical antipsychotics are less likely to cause movement disorders than classical antipsychotics and they are being frequently prescribed in disorders that can be associated with catatonia. Therefore, the important question that arises is whether atypical antipsychotics have a role to play in the treatment of catatonia.

Materials and methods

A Medline search was performed to locate papers on the use of atypical antipsychotics in catatonia published between 1970 and 31st December 2004.

Results

The literature on the use of atypical antipsychotics in catatonia consists of case reports and retrospective studies. In most cases of non-MC a reduction of the catatonic symptoms is reported upon treatment with atypical antipsychotics. Cases of MC relate mainly to the neuroleptic malignant syndrome (NMS), which is considered as an iatrogenic stuporous variant of MC caused by antipsychotics.

Conclusion

There are indications that atypical antipsychotics may be useful in non-MC. As a consequence, one should not only focus on the possible extrapyramidal and autonomic side effects of these drugs, but also on the possible beneficial effects on certain brain functions and on the catatonic symptomatology. However, randomized controlled trials are needed to evaluate the effect of these drugs, and caution is advisable, since cases of NMS have been linked to treatment with atypical antipsychotics. There is no evidence to prescribe atypical antipsychotics in MC.

The Role of Physical Examinations in Psychiatry as Illustrated in a Case of Neuroleptic Malignant Syndrome Versus Viral Encephalitis: A Case Report and Literature Review

Although a standard psychiatric evaluation includes a physical examination, there are no guidelines on the components of a comprehensive physical examination during psychiatric patient encounters. The mental status examination is frequently considered the psychiatric physical examination equivalent. We report a 59-year-old male inpatient on a medical unit who had hyperthermia, an altered mental status, muscle rigidity, and elevated white blood cell count and creatine phosphokinase level. He had been taking risperidone 1 mg orally every 12 hours for two months. His primary treatment team suspected Neuroleptic Malignant Syndrome (NMS), but the consulting psychiatrist detected equivocal findings on physical examination and recommended a broader differential diagnosis. Further investigations revealed the possibility of an infection. The patient was positive for immunoglobulin G (IgG) antibodies to HSV-1 and HSV-2 on cerebrospinal fluid analysis. He was then treated for Herpes Simplex Encephalitis (HSE) with an oral course of acyclovir. Although NMS was low in the diagnostic ranking, given the possibility of an atypical form and the lethality of this condition if untreated, he also received intravenous lorazepam at 2 mg every six hours. He experienced full resolution of his symptoms and was stable for discharge. HSE and NMS are two examples of neuropsychiatric disorders with similar presenting symptoms.

HSE frequently presents with predominantly psychiatric symptoms, such as paranoia, hallucinations, and an altered mental status. Consequently, it is typically not the first diagnosis that comes to mind, especially when these symptoms occur in a patient already being treated by a psychiatrist. Confirmation bias is the tendency for an individual to focus on the information that aligns with one’s preconceptions and to ignore information that defies it. Due to this bias, physicians may attribute all symptoms of a known psychiatric patient to a psychiatric cause, instead of considering an organic etiology. In this case, the evaluation by the psychiatrist was crucial in guiding the treatment team to a diagnosis of HSE. This is important since a delayed treatment of HSE can be fatal. The literature review reveals a general consensus among psychiatrists on the value of physical examinations in patient care. In spite of this, the majority of psychiatrists seldom perform physical examinations due to concerns over skill atrophy and the potential that doing so may change the therapeutic dynamic. Others have disputed these claims and have argued that physical examinations in a psychiatric setting will not only strengthen the perception of a psychiatrist as a physician by the patient but will also allow for better care of psychiatrically ill patients. Psychiatrists should remember that they are oftentimes the sole healthcare provider for psychiatric patients and that these patients may not have the access to primary care physicians and may lack the ability to explain their symptoms or advocate for themselves. Therefore, incorporating an emphasis on performing physical examinations during psychiatry residency training and in continuing medical education programs for psychiatrists is essential.

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.

Hyperthermia syndromes in psychiatry

Presence of fever in psychiatric patients may signify a number of potentially fatal conditions. Several of these are related to treatments (e.g. neuroleptic malignant syndrome with antipsychotics, serotonin syndrome with serotonergic antidepressants, and malignant hyperpyrexia with anaesthesia used for administration of electroconvulsive therapy) or exacerbated by them (e.g. malignant catatonia with antipsychotics). New classes of drug treatment may be changing the epidemiology of these disorders. We suggest that an initial diagnosis of hyperthermia syndrome is clinically useful as there are some important commonalities in treatment. We outline a systematic approach to identify a particular subtype of hyperthermia syndrome and the indications for more specific treatments where available.

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.

Olanzapine-Induced Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening idiosyncratic side effect resulting from neuroleptic drugs. NMS mainly occurs in patients treated with high-potency typical antipsychotics, but rarely caused by atypical antipsychotics. Although NMS is less common with atypical antipsychotic, but it seems that its incidence is rising due to increased administration of such drugs. We present the case of a 27-year-old man with a history of paranoid schizophrenia that showed signs consistent with NMS that occurred after treatment with olanzapine. The patient was adherent to treatment. He had decreased level of consciousness, muscle rigidity, diaphoresis, fever, drooling, urinary incontinence, and high blood pressure. This patient illustrates that NMS can occur due to treatment with atypical antipsychotic drugs like olanzapine, particularly in the presence of risk factors. This phenomenon is often unrecognized, underdiagnosed, or not treated properly. Physicians should be aware that NMS with extrapyramidal syndrome could occur with olanzapine at steady state doses without recent dosage adjustments or titration. It is essential that adequate and safe dose of medication is chosen and the patient is monitored by the signs and symptoms of this lethal syndrome.

Neuroleptic malignant syndrome: an easily overlooked neurologic emergency

Neuroleptic malignant syndrome is an unpredictable iatrogenic neurologic emergency condition, mainly arising as an idiosyncratic reaction to antipsychotic agent use. It is characterized by distinctive clinical features including a change in mental status, generalized rigidity, hyperpyrexia, and dysautonomia. It can be lethal if not diagnosed and treated properly. Mortality and morbidity attributed to this syndrome have recently declined markedly due to greater awareness, earlier diagnosis, and intensive care intervention. In most cases, the syndrome occurs as a result of a rapid increase in a dose of neuroleptic, especially one of the long-acting ones. Pathophysiology behind this syndrome is attributed to a dopamine receptor blockade inside the neurons rendered by the offending drug and excessive calcium release from the sarcoplasmic reticulum of skeletal myocytes. Laboratory tests, although not diagnostic, may assist in assessing the severity of the syndrome and also the consequent complications. The syndrome has been described in all age groups and occurs more in males than in females. Genetics appears to be central regarding the etiology of the syndrome. Stopping the use of the offending agent, cold intravenous fluids, and removal of the causative agent and its possible active metabolites is the cornerstone of treatment. Periodic observation of psychotic patients recently started on antipsychotic medications, especially those being treated with depot preparations, may aid to an early diagnosis of the syndrome and lead to early treatment.

Characterization and Clinical Management of Clozapine-Induced Fever

Objective:

To characterize clozapine-induced fever and suggest clinically relevant management recommendations.

Data Sources:

Literature was accessed through MEDLINE (1966–June 2007) using the terms clozapine, fever, and adverse effects. In addition, reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

All English-language articles about human studies ot fever associated with the use of clozapine were evaluated.

Data Synthesis:

Mild to high-grade fever frequently accompanies clozapine therapy. Fever usually occurs within 10–15 days after treatment initiation and has been reported to last between 2 and 4 days. The mechanism and clinical implications of clozapine-induced fever are unclear. The primary concern for clinicians, with regard to these fevers, is the possibility of 2 serious conditions: agranulocytosis with infection or neuroleptic malignant syndrome (NMS). However, the presence of fever during clozapine therapy does not appear to predict agranulocytosis, NMS, or an increased rate of drug discontinuation at 1 year.

Conclusions:

Available data suggest that clozapine-induced fevers are benign: once infectious and other medical causes for fever are ruled out, clozapine therapy can be continued.

Neuroleptic Malignant Syndrome with Delayed Onset of Fever Following Risperidone Administration

Objective:

To report and discuss a case of neuroleptic malignant syndrome (NMS) with delayed onset of fever in a patient taking risperidone.

Case Summary:

A 59-year-old white female presented with progressive weakness, confusion, and disorientation 10 days after restarting risperidone 2 mg/day therapy for bipolar disorder. She had taken risperidone for several years prior to this episode and had stopped it for approximately 3 weeks; risperidone was discontinued on admission. The patient's creatine kinase (CK) level was elevated (901 IU/L; reference range 39–162) on admission and increased to 1991 IU/L the following day. She was initially afebrile and had no muscular rigidity. Elevated temperature (38.1°C) did not occur until hospital day 2. The patient was successfully treated with diazepam, bromocriptine, and dantrolene and suffered no long-term sequelae.

Discussion:

Other clinicians have reported atypical presentations of NMS in patients taking newer neuroleptic agents. Although this patient met diagnostic criteria for NMS, the hallmark symptoms of fever and muscle rigidity were delayed in onset. Also, the patient never remained febrile for more than 24 hours and her maximum temperature was only 38.6°C. An objective causality assessment suggests that this case of NMS was probably related to restarting risperidone.

Conclusions:

Because of the life-threatening nature of this syndrome, clinicians should consider NMS in afebrile patients presenting with diaphoresis, changes in level of consciousness, mutism, tremors, tachycardia, leukocytosis, and elevated CK levels.

Therapeutic Options in the Treatment of Clozapine-Induced Adverse Effects

Objective:

To review the therapeutic options in the management of clozapine-induced adverse effects.

Data Sources:

A MEDLINE search (from 1966 to present) was conducted, and English-language studies and review articles were retrieved to review the adverse effects of clozapine and their management.

Study Selection and Data Extraction:

All studies evaluating clozapine's adverse effects, such as agranulocytosis, seizures, neuroleptic malignant syndrome, hypersalivation, weight gain, sedation, fatigue, orthostatic hypotension, eosinophilia, delirium, new-onset diabetes, constipation, nausea, tachycardia, myocarditis, and pancreatitis, and their management were included.

Data Synthesis:

Clozapine, an atypical antipsychotic that has been proven effective and comparable, as well as superior, to conventional antipsychotics in treatment-resistant schizophrenia, is also being used in the treatment of a wide variety of other psychiatric conditions, including suicidal ideation, tardive dyskinesia, and affective disorders such as depression, bipolar disorders, and schizoaffective disorder. Although clozapine exhibits a markedly low incidence of extrapyramidal symptoms compared with similar medications, it has other adverse effects, some of which are potentially life threatening, requiring careful monitoring. The adverse effects of clozapine range from benign drooling, weight gain, nausea, and constipation, to life-threatening agranulocytosis, seizures, and neuroleptic malignant syndrome (NMS). Mandatory periodic white blood cell monitoring has resulted in dramatic reduction in mortality due to clozapine-induced agranulocytosis, promoting high adherence by patients. Prompt diagnosis and treatment of adverse effects of clozapine has also been effective in reducing complications, including mortality due to other serious adverse effects such as NMS and seizure. Other adverse effects are comparatively benign and can be managed effectively.

Conclusions:

Clozapine has a wide variety of adverse effects, some of which are potentially life threatening. Clinicians should be aware of possible severe complications and emergency management. Differentiating between minor and major adverse effects and initiating appropriate intervention is essential for a positive therapeutic outcome when prescribing clozapine.

Practical approach to management of catatonia

In this article, we discuss important issues in the management of catatonic symptoms in busy clinical settings. Catatonic symptoms are common among inpatients, not only in psychiatry but also in acute medicine and neurology. Prompt recognition of these symptoms is easy if clinicians maintain a high index of suspicion. Early diagnosis and treatment can reduce the significant morbidity and mortality associated with these cases. Speedy investigation to rule out organic catatonia and identify dangerous complications forms an important part of management. Early treatment with benzodiazepines can aid diagnosis and shorten the duration of catatonia, thereby improving outcomes. Electroconvulsive therapy has an important role where benzodiazepines have been ineffective, but antipsychotics can be potentially harmful. There are a number of other treatment options that are less robustly evidence-based, but supportive management is essential in all cases.

Catatonia versus neuroleptic malignant syndrome: the diagnostic dilemma and treatment

Catatonia is a syndrome, comprised of symptoms such as motor immobility, excessive motor activity, extreme negativism, and stereotyped movements. Neuroleptic is able to induce catatonia like symptoms, that is, the neuroleptic malignant syndrome (NMS). In NMS, patients typically show symptoms such as an altered mental state, muscle rigidity, tremor, tachycardia, hyperpyrexia, leukocytosis, and elevated serum creatine phosphorous kinase. Several researchers have reported studies on catatonia and the association between catatonia and NMS, but none were from this part of the eastern India. In our case, we observed overlapping symptoms of catatonia and NMS; we wish to present a case of this diagnostic dilemma in a patient with catatonia, where a detailed history, investigation, and symptom management added as a great contribution to the patient's rapid improvement.

Retrospective chart review on exposure to psychotropic medications associated with neuroleptic malignant syndrome

OBJECTIVE

To investigate the association between neuroleptic malignant syndrome (NMS) and levels of antipsychotic exposure.

METHOD

Electronic health record data systematically screened from a large mental health service provider in southeast London provided 67 NMS cases which were individually matched with 254 controls on age, gender, and primary psychiatric diagnosis. Data on psychotropic agents, combinations, dose, and dose change of antipsychotic prescriptions over the preceding 5 (oral agents) or 15 days (depot agents) were extracted and compared between groups using conditional logistic regression models.

RESULTS

NMS was associated with higher number of antipsychotic agents used, use of first-generation agents or aripiprazole, use of first-generation agents only or cross-generation agents, and higher mean and maximum daily doses. In further analyses, associations with antipsychotics type remained significant when adjusted for dose, but those with dose were attenuated following adjustment for type. The specific use of haloperidol, aripiprazole, depot flupentixol, and benzodiazepines was independently associated with NMS. Non-white ethnicity was also found to be associated with NMS.

CONCLUSION

NMS was primarily associated with type of antipsychotic and polypharmacy rather than overall dose. Variation in risk by ethnicity requires further research.

Case reports of neuroleptic malignant syndrome in context of quetiapine use

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

Two unusual complications of neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a rare but well described complication of the administration of antipsychotic agents. Compartment syndrome, with increased pressures within the confined space of fascial sheaths leading to compression damage of the contained tissue, similarly is well described. Brachial plexus injuries caused by patient malposition are also very rare but a few cases have been reported. We report a case where these three complications occurred together. This was attributable to the patient developing NMS whilst asleep in the prone position overnight.

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse event associated with the use of antipsychotics (AP). The objective of this study was to investigate the profile of cases of NMS and to compare our findings with those published in similar settings. A series of 18 consecutive patients with an established diagnosis of NMS was analyzed, gathering data on demography, symptoms and signs. Two thirds of all cases involved woman with a past medical history of psychiatric disorder receiving relatively high doses of AP. The signs and symptoms of NMS episodes were similar to those reported in other series and only one case had a fatal outcome, the remaining presenting complete recovery. As expected, more than two thirds of our cases were using classic AP (68%), however the clinical profile of these in comparison with those taking newer agent was similar. Newer AP also carry the potential for NMS.

A case of catatonia and neuroleptic malignant syndrome probably associated with antipsychotic in Korea

Several studies have reported on catatonia caused by the use of antipsychotic drugs and on the association between catatonia and neuroleptic malignant syndrome (NMS), but none has reported such a case in Korea. Here, we report the case of a 20-year-old woman whose catatonia and NMS appeared associated with the administration of an atypical antipsychotic drug. We discuss the association between NMS and catatonia due to neuroleptic use.

Risk of neuroleptic malignant syndrome in patients with bipolar disorder: a retrospective, population-based case-control study

INTRODUCTION

Current data regarding risk factors of neuroleptic malignant syndrome (NMS) are limited. This study aims to examine factors associated with increased risk of NMS in patients with bipolar disorder.

METHODS

A retrospective, population-based, case-control study was performed using a medical claims database covering January 1998 to December 2002. Fifty cases with a diagnosis of NMS were identified and matched with 800 controls. Conditional logistic regression analysis was used to estimate crude and adjusted odds ratios (ORs) of risk of NMS.

RESULTS

Antipsychotic use was associated with an increased risk of NMS after controlling for other pharmacologic and clinical factors (OR = 2.36, 95% CI = 1.08-5.19). Other factors associated with an increased risk of NMS included being male (OR = 2.07, 95% CI = 1.07-4.02), confusion (OR = 2.91, 95% CI = 1.17-7.28), dehydration (OR = 3.99, 95% CI = 1.50-10.57), delirium (OR = 4.93, 95% CI = 2.07-11.72), and extrapyramidal symptoms (OR = 3.50, 95% CI = 1.10-11.09).

CONCLUSIONS

Given the widespread use of antipsychotics for the treatment of bipolar disorder, clinicians should be vigilant of the potential pharmacologic and clinical factors associated with increased risk of NMS in patients with bipolar disorder.

Zuclopenthixol-induced neuroleptic malignant syndrome presenting as fever of unknown origin, hyperglycaemia and acute myocardial infarction in a 60-year-old man

Neuroleptic malignant syndrome (NMS) is a rare clinical condition and potentially life-threatening complication of antipsychotic medications. We report a patient with an atypical presentation of NMS. A 60-year-old man with schizophrenia was admitted to our hospital with disturbed consciousness, fever and marked extrapyramidal rigidity both in the upper and lower extremities. He had been given i.m. zuclopenthixol 200 mg/month but had not taken the last dose. Laboratory investigations showed that creatinine phosphokinase 428 IU/l (normal up to 130), lactate dehydrogenase 772 IU/l (normal up to 450), blood glucose 256 mg/dl (65-110). Urine analyses revealed ketonuria. White blood cell (WBC) count was 6100 cells/mm(3). Therefore, the patient was diagnosed as having NMS and antipsychotic medications were stopped. Adequate hydration was provided and bromocryptine 5 mg was started three times a day. Despite treatment, the patient died due to acute myocardial infarction after 3 days of hospitalization.

Catatonia as a risk factor for the development of neuroleptic malignant syndrome: report of a case following treatment with clozapine

Catatonia is characterized by the predominance of psychomotor abnormalities and shares many clinical, biological and treatment response features with the neuroleptic malignant syndrome (NMS), a rare adverse reaction to psychoactive medications. It has been advocated that the two conditions should be placed along the same spectrum of disorders. A case of a 49-year-old woman, who developed NMS while on low dose clozapine soon after recovering from catatonia, is presented. The potential relationship between catatonia and NMS is discussed in the light of the existing literature, and attention is drawn to the risk for clozapine-induced NMS in catatonic patients.

Neuroleptic malignant syndrome developing after acute overdose with olanzapine and chlorpromazine

Neuroleptic malignant syndrome (NMS) is a relatively uncommon side effect that may develop after a recent increase in the therapeutic dose of an antipsychotic medication or the addition of a new agent in therapeutic doses.

CASE REPORT

We report a case of NMS developing in a 36-year-old female patient 2 days following deliberate self-poisoning with 30 x 10-mg olanzapine tablets, 7 x 100-mg chlorpromazine tablets and an unknown amount of escitalopram. These were the patient's own medications. She had not been taking these for several weeks. The patient initially presented with sedation from her overdose which resolved over the next 24 hours. Following this, over the subsequent 24 hours, she became progressively confused, ataxic, hypertonic, ferbrile and tachycardic, with marked lead pipe rigidity of the limbs. Head CT, lumbar puncture and septic screen were all negative. She was treated with intravenous midazolam infusion, nasogastrically administered bromocriptine, external cooling and was mechanically ventilated. She gradually improved over a period of 10 days, with residual confusion lasting another week, and was discharged well with no deterioration from her premorbid neurologic state.

CONCLUSION

To our knowledge, although there are numerous cases reported with therapeutic use, NMS has not been reported to develop following acute olanzapine overdose. Clinicians should be aware that this may be an uncommon side effect of antipsychotic medication.

Suspected Neuroleptic Malignant Syndrome During Quetiapine-Clozapine Cross-Titration

Neuroleptic malignant syndrome (NMS) is a physiologic phenomenon that has been associated with the use of both first- and second-generation antipsychotics resultant to their ability to block dopamine blockade in the basal ganglia and hypothalamic regions of the brain. The typical reaction involves the presentation of muscle rigidity, changes in mental status, temperature elevation, labile blood pressure, and elevations in creatinine kinase and white blood cell counts. The reaction is most often reported early in the course of therapy but is well documented to have the potential to occur at any point in time. Untreated NMS can be fatal, often from secondary causes such as deep venous thrombosis and pulmonary embolism. Treatment involves immediate discontinuation of the offending agent, supportive therapy of clinical symptoms, and may include the use of the skeletal muscle relaxant, dantrolene sodium, or the dopaminergic agents bromocriptine or amantadine. In this case, we present a patient who developed symptoms of NMS during the cross-taper and conversion from quetiapine to clozapine. The patient was treated for NMS; however, his clinical diagnosis was never able to be definitively determined as he was initially evaluated for septicemia and later treated for suspected bacterial infection with antibiotics, and clozapine-associated side effects cannot be ruled-out as a contributing source to the clinical presentation. The estimated Naranjo Scale score for this case report is 3.

Catatonia, neuroleptics and brain damage--a case report

Catatonia is a syndrome that encompasses multiple motor signs. It can be the only presenting clinical feature in a patient with underlying multiple neuropsychiatric syndromes. The authors present a case of amisulpiride-induced catatonia, further evaluation suggested neuroleptic malignant syndrome (NMS) and showed the occurrence of temporal lobe epilepsy (TLE) and underlying brain pathology with marked frontoparietal atrophy and periventricular white matter hyperintensities. The pathological substrate of catatonia and its complex association with neuropsychiatric syndromes are discussed.

Olanzapine-induced neuroleptic malignant syndrome in a patient with paranoid schizophrenia

A case of a male patient with schizophrenic illness who developed neuroleptic malignant syndrome (NMS) following treatment with olanzapine is reported. Although typical neuroleptics are more frequently associated with NMS, atypical antipsychotics may also cause NMS. Case reports have been published concerning NMS and clozapine,(1) risperidone(2) and olanzapine.(3-6) This case report emphasizes the importance of being cautious when rapidly increasing doses of olanzapine are used in patients with psychiatric illnesses.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

CORRESPONDENCE

The recent article in your journal by Khan and Tham (vol 69(3), 2008, p. 171) usefully highlights a case of neuroleptic malignant syndrome associated with the atypical antipsychotic drug quetiapine.

Atypical antipsychotics and newer antidepressants

Atypical antipsychotics and newer antidepressants are commonly prescribed medications responsible for tens of thousands of adverse drug exposures each year. The emergency medicine physician should have a basic understanding of the pharmacology and toxicity of these agents. This knowledge is crucial to providing proper care and timely management of patients presenting with adverse drug effects from exposure to atypical antipsychotics and newer antidepressants.

Neuroleptic malignant syndrome induced by ziprasidone on the second day of treatment

Neuroleptic malignant syndrome (NMS) is the rarest and most serious of the neuroleptic-induced movement disorders. We describe a case of neuroleptic malignant syndrome (NMS) associated with the use of ziprasidone. Although conventional neuroleptics are more frequently associated with NMS, atypical antipsychotic drugs like ziprasidone may also be a cause. The patient is a 24-year-old male with a history of schizophrenia who developed signs and symptoms of NMS after 2 days of treatment with an 80-mg/day dose of orally administrated ziprasidone. This case is the earliest (second day of treatment) NMS due to ziprasidone reported in the literature.

Neuroleptic malignant syndrome and serotonin syndrome

This chapter is focused on drug-induced hyperthermia with special regard to use of antipsychotics and antidepressants for the treatment of schizophrenia and major depression, respectively. Neuroleptic malignant syndrome (NMS) develops during the use of neuroleptics, whereas serotonin syndrome is caused mainly by serotoninergic antidepressants. Although both syndromes show various symptoms, hyperthermia is the main clinical manifestation. In this review we describe the historical background, clinical manifestations, diagnosis, and differential diagnosis of these two syndromes based on our observations on the experimental and clinical data.

Treatment of psychosis: 30 years of progress

Thirty years ago, psychiatrists had only a few choices of old neuroleptics available to them, currently defined as conventional or typical antipsychotics, as a result schizophrenics had to suffer the severe extra pyramidal side effects. Nowadays, new treatments are more ambitious, aiming not only to improve psychotic symptoms, but also quality of life and social reinsertion. Our objective is to briefly but critically review the advances in the treatment of schizophrenia with antipsychotics in the past 30 years. We conclude that conventional antipsychotics still have a place when just the cost of treatment, a key factor in poor regions, is considered. The atypical antipsychotic drugs are a class of agents that have become the most widely used to treat a variety of psychoses because of their superiority with regard to extra pyramidal symptoms. We can envisage different therapeutic strategies in the future, each uniquely targeting a different dimension of schizophrenia, be it positive, negative, cognitive or affective symptoms.

The catatonic dilemma expanded

Catatonia is a common syndrome that was first described in the literature by Karl Kahlbaum in 1874. The literature is still developing and remains unclear on many issues, especially classification, diagnosis, and pathophysiology. Clinicians caring for psychiatric patients with catatonic syndromes continue to face many dilemmas in diagnosis and treatment. We discuss many of the common problems encountered in the care of a catatonic patient, and discuss each problem with a review of the literature. Focus is on practical aspects of classification, epidemiology, differential diagnosis, treatment, medical comorbidity, cognition, emotion, prognosis, and areas for future research in catatonic syndromes.

Fatal neuroleptic malignant syndrome in a previously long-term user of clozapine following its reintroduction in combination with paroxetine

A 77-year-old patient with initial behavioral and psychological symptoms of dementia was treated with clozapine (50 mg/daily). Since no clinical benefit was apparent, clozapine was discontinued after six weeks and the patient started on paroxetine (20 mg/daily). After three weeks on paroxetine, he was given another trial of clozapine at a starting dosage of 25 mg/daily. While clozapine had previously been well tolerated, this time he rapidly developed fever, mental confusion, lethargy, muscle spasms and rigidity. The diagnosis of neuroleptic malignant syndrome was delayed, because there was no leukocytosis and serum creatine phosphokinase was initially not elevated. Subcutaneous apomorphine was then given but, after an initial improvement, the patient developed a multiple organ failure syndrome and died.

A review of clozapine safety

Clozapine is a distinctive antipsychotic agent, having a unique clinical profile and an idiosyncratic safety profile. More so than with other agents, the weighting of its adverse event profile is critical, in order to counterbalance its clear clinical advantages. The safety issues with clozapine are in a number of areas, some of which are considered medical emergencies and potentially life-threatening. These include haematological (neutropenia and agranulocytosis), CNS (seizures), cardiovascular (myocarditis and cardiomyopathy), metabolic (diabetes), gastrointestinal and neuromuscular. Understanding the safety profile of clozapine allows an informed use of the agent that can maximise its clear clinical benefit and minimise the known risks.

Neuropsychiatric sequelae of neuroleptic malignant syndrome

The authors review the literature on persistent sequelae of neuroleptic malignant syndrome (NMS). They highlight the clinical presentations, assessment, and management of persistent sequelae and stress the need to take preventive steps to minimize their occurrence. The authors conducted a Medline and PubMed search for papers on residual sequelae of NMS. They cross-referenced the available papers and "operationalized" the diagnostic criteria for persistent neuropsychiatric sequelae. A total of 31 cases of neuropsychiatric sequelae of NMS were identified. With reduction in mortality from NMS, persistent sequelae of NMS have assumed clinical importance. Long-term sequelae persist for weeks to months after amelioration of an acute episode. Individuals with a preexisting CNS insult are more predisposed to develop persistent sequelae. A high index of awareness for persistent sequelae is warranted because antipsychotics are widely used for psychiatric disorders besides schizophrenia. Awareness of such outcomes and the use of evidence-based strategies to minimize risk factors will help clinicians in reducing the persistent sequelae of NMS.