Neuroleptic Malignant Syndrome Associated with Lithium Toxicity

A real-world pharmacovigilance study of neuroleptic malignant syndrome based on FDA adverse event reporting system

Background

Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening adverse drug reaction. This study aims to identify the most prevalent drugs associated with the risk of NMS according to the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database.

Methods

Analyses were performed using data from the FAERS database from January 2004 to June 2024. Single-drug signals were evaluated using the reporting odds ratio (ROR), proportional reporting ratio (PRR), information component (IC), and empirical Bayes geometric mean (EBGM). Meanwhile, comparisons were performed with drug labels. Additionally, subgroup analysis was conducted, focusing on adverse drug reaction signals among populations of different genders and age groups.

Results

A total of 10,433 adverse event reports related to NMS were identified, with the top 50 drugs ranked by ROR mainly involving antipsychotics (18, 36%), antiparkinson drugs (10, 20%), antidepressants (7, 14%), antiepileptics (3, 6%), anxiolytics (3, 6%), as well as hypnotics and sedatives (3, 6%). NMS is more prevalent in males (5,713, 54.76%). Among the top 20 drugs with the strongest signal strength, the pediatric group showed an additional presence of benzodiazepines and antiepileptic drugs compared to the adult group.

Conclusion

The current comprehensive pharmacovigilance study identified more drugs associated with NMS and provides references to clinicians for clinical practice. Also, further research is needed to investigate the causal relationship between these drugs and NMS.

Acute kidney injury induced lithium toxicity with concomitant neuroleptic malignant syndrome

Lithium, despite being an indispensable agent in the treatment of psychiatric disorders, has a narrow therapeutic index and needs to be carefully administered. Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication due to central dopaminergic blockade. This case report illustrates the challenges in lithium therapy particularly related to the development of NMS when further risk factors such as polypharmacy and dehydration are present. We report a case of a 50-year-old man with underlying bipolar affective disorder who was previously able to tolerate olanzapine and lithium well, however developed chronic lithium toxicity due to diminished lithium elimination in acute kidney injury following a two-week history of viral acute gastroenteritis. He also developed NMS which could either be triggered independently by olanzapine; lithium toxicity; or attributed by a synergistic combination from lithium and olanzapine which led to an enhanced neurotoxicity in an already unstable dopaminergic pathway. Fluid therapy and supportive care allowed the patient to recover, and he was discharged well with a lower potency neuroleptic with slow dose titration.

Long prodromal symptoms of neuroleptic malignant syndrome in patient with intellectual developmental disorder-A case report

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a rare and potentially life-threatening condition that may arise at any point during treatment and is often associated with adverse reactions to dopamine-blocking agents. This syndrome is normally characterized by features such as muscle rigidity, alteration in consciousness, autonomic instability, and leukocytosis.

AIM

The aim of this study is to investigate a borderline intellectual functioning (BIF) case in which NMS with insidious disease progression and long prodromal symptoms was developed.

CASE PRESENTATION

The investigated patient was a 38-year-old female diagnosed with bipolar disorder and a variety of corresponding disorders. The patient exhibited gastrointestinal symptoms and restlessness in the weeks leading up to the study, subsequent to the administration of elevated doses of haloperidol, risperidone, and lithium. In addition, she was hospitalized for restlessness and aggressiveness in the summer of 2023. Furthermore, due to her chief complaint, she received parenteral haloperidol twice in the emergency room, subsequently experiencing fever, altered consciousness, generalized rigidity, and dysphagia. Moreover, the patient's initial creatine phosphokinase (CPK) level was 2550 IU/L, and she was hospitalized in an intensive care unit with the diagnosis of NMS for 8 days.

CONCLUSIONS

This case study highlights the necessity of being attentive about prodromal symptoms of NMS and emergent interventions.

A Case of Neuroleptic Malignant Syndrome in the Context of Lithium Toxicity and Aripiprazole Use

OBJECTIVE

Neuroleptic malignant syndrome (NMS) is a rare life-threatening condition that providers should be cognizant of when prescribing dopamine-receptor antagonists. Atypical antipsychotic agents were initially considered to have a lower risk of inducing the development of NMS compared with conventional antipsychotic. Considerable evidence, however, has suggested that atypical antipsychotics are associated with NMS, including the partial dopamine agonist, aripiprazole. There is growing evidence that other psychotropics, including lithium, cause this condition. Here, the authors present a case of a patient who developed NMS from lithium and aripiprazole and provide a literature review of reported NMS cases with either psychotropic.

METHOD AND RESULTS

The authors report the case of 60-year-old male patient who developed NMS over a hospital course during which both aripiprazole and lithium were prescribed. In addition, a literature review was performed and a summary of cases of NMS induced by either lithium and/or aripiprazole is provided.

CONCLUSIONS

This case adds to the growing body of literature of aripiprazole and lithium-induced NMS. Only 2 other cases are reported where concomitant aripiprazole and lithium use lead to NMS. Interestingly, our patient did develop lithium toxicity during hospitalization, but the NMS diagnosis occurred after lithium toxicity resolved. This varies from the other 2 cases where NMS developed despite lithium levels always being therapeutic. Unfortunately, there are more questions than answers surrounding this rare complication involving these 2 psychotropics and clinical vigilance is warranted when using these psychotropics especially in cases where aripiprazole and lithium are used in combination.

Challenges in the Clinical Diagnosis of Lithium Toxicity: A Case Report

Lithium, a medication commonly used to treat bipolar disorders, has a narrow therapeutic index, putting patients at risk of lithium toxicity. Such toxicity could entail neurological-related complications and could be precipitated by several factors. In this paper, the authors discuss a case of a middle-aged woman taking lithium for bipolar disorder who presented to the emergency department with altered mental status, tremors, generalized weakness, and dysarthria. Multiple differential diagnoses were considered during her hospitalization, which included an admission to the intensive care unit. This case highlights the variability of lithium toxicity presentations and its management challenges. Further research is needed to understand such manifestations, potential precipitating factors, differential diagnoses, and effective detection and management.

Neuroleptic Malignant Syndrome From Oxcarbazepine and Topiramate Withdrawal: An Unusual Case

Neuroleptic malignant syndrome (NMS) is a rare, but fatal adverse reaction that is most commonly seen with typical antipsychotic medications. However, NMS can also be triggered by other dopamine-modulating agents that physicians are unlikely aware of, leading to being underdiagnosed or precluding early recognition of the syndrome. We describe a case involving a 20-year-old male who presented to the emergency department with altered mental status and failure to thrive. On admission, he subsequently developed an insidious onset of muscle rigidity and autonomic instability, and laboratory work-up was significant for leukocytosis, transaminitis, and elevations in creatinine phosphokinase, lactate, and C-reactive protein. After a battery of negative diagnostic tests, his clinical features fulfilled the NMS criteria by a diagnosis of exclusion, even in the absence of any antipsychotic regimen or dopaminergic medications. Management with dantrolene, amantadine, and aggressive fluid therapy provided a gradual return of the patient's baseline mentation along with normalization in laboratory assessments. In this novel case of NMS, we suspect oxcarbazepine and topiramate withdrawal as possible attributing factors for the patient's presentation. This article emphasizes the need for hypervigilance in future cases with high suspicion of NMS, in addition to raising a broader clinical awareness of other potential etiologies of NMS that are not restricted to only antipsychotic medications. We further discuss a review of the pathophysiology, various etiologies, clinical features, diagnostic criteria, treatment plans, and complications of NMS.

Lamotrigine, quetiapine and aripiprazole-induced neuroleptic malignant syndrome in a patient with renal failure caused by lithium: a case report

BACKGROUND

Neuroleptic malignant syndrome (NMS) may be induced by atypical antipsychotic drugs (AAPDs) such as aripiprazole, olanzapine, risperidone and quetiapine, either as a single treatment or in combination with other drugs. A case of NMS following the administration of lamotrigine, aripiprazole and quetiapine in a patient with bipolar disorder, and with renal failure caused by toxic lithium levels has not been reported.

CASE PRESENTATION

A 51-year-old female patient with a 27-year history of bipolar disorder, being treated with lithium, fluoxetine, olanzapine, gabapentine, perazine and biperiden, was admitted to the hospital due to depressed mood and delusions. A urinary tract infection was diagnosed and antibiotic therapy was initiated. After 5 days of treatment her physical state deteriorated and she developed a fever of 38.4 °C. Her laboratory results revealed a toxic level of lithium (2.34 mmol/l). Acute renal failure was diagnosed and the lithium was withdrawn. After stabilization of her condition, and despite her antipsychotic treatment, further intensification of delusions and depressed mood were observed. All drugs being taken by the patient were withdrawn and lamotrigine and aripiprazole were initiated. Due to the insufficient effectiveness of aripiprazole treatment and because of problems with sleep, quetiapine was added, however further treatment with this drug combination and an increase of quetiapine to 400 mg/d eventually caused NMS. Amantadine, lorazepam and bromocriptine were therefore initiated and the patient's condition improved.

CONCLUSION

This case report indicates that concurrent use of multiple antipsychotic drugs in combination with mood stabilizers in patients with organic disorders confers an increased risk of NMS development.

Neuroleptic malignant syndrome: A case report

Electroconvulsive therapy (ECT) is an increasingly popular treatment for drug-resistant depression that may have utility for some patients with neuroleptic malignant syndrome (NMS) who are unresponsive to pharmacotherapy. Using a case study as an example, this article discusses the diagnosis of a patient with NMS, the use of ECT as a treatment for NMS, and the importance of nursing care for these patients.

Acetyl-11-keto-β-boswellic acid attenuates titanium particle-induced osteogenic inhibition via activation of the GSK-3β/β-catenin signaling pathway

Rationale: Peri-prosthetic osteolysis (PPO) is mainly induced by wear particles and represents the leading cause of implant failure and revision surgery. Previous studies have identified mitigation of wear particle-induced inflammation and bone resorption as the main approaches to treat PPO. Recently, wear particle-induced reduction of bone formation around the prosthesis was identified as a major factor in the development of PPO. Acetyl-11-keto-β-boswellic acid (AKBA), a derivative of frankincense, has been shown to play a potential role in bone metabolism. However, whether AKBA enhances bone formation in wear particle-induced osteolysis remains unknown. In this study, we examined whether AKBA attenuates titanium particle-induced osteogenic reduction.

Methods: Titanium particles were used to induce osteolysis in murine calvaria, and micro-CT and histological analyses were used to evaluate the results. Mouse osteoblast cells, MC3T3-E1 were co-cultured with titanium particles to determine their effect on osteoblast formation in vitro.

Results: We demonstrated that AKBA treatment significantly inhibited titanium particle-induced osteogenic inhibition by enhancing osteogenesis both in vivo and in vitro. AKBA treatment also enhanced the phosphorylation of GSK-3β, decreased the degradation of β-catenin, and increased the translocation of β-catenin from the cytoplasm to the nucleus. Taken together, these results showed that AKBA treatment attenuated titanium-induced osteogenic inhibition by activating the GSK-3β/β-catenin signaling pathway.

Conclusion: These findings suggest that AKBA is a promising new target in the prevention and treatment of PPO.

Status Epilepticus as an Unusual Manifestation of Heat Stroke

Heat stroke (HS) is a medical emergency and life threatening condition, characterized by body temperature over 40°C. This can lead to dysfunction of multiple organs such as the heart, liver, kidneys, lungs, blood coagulation system, and central nervous system. Neurological complications include change in consciousness, cerebellar dysfunction, convulsions, aphasia, muscular weakness, and parkinsonism. Cerebellar syndrome is the most common neurological finding in HS. We report a case of HS presenting with status epilepticus, without any other neurological manifestations. A 42 year old man, previously diagnosed with bipolar disorder, was admitted to the emergency room with high fever and repetitive generalized tonic-clonic seizures. He had been found unconscious after 4 hours of heavy physical work under extremely hot weather conditions. He was diagnosed with HS accompanied by status epilepticus, and treated with emergency body cooling and antiepileptics. Five days after admission, he regained consciousness and the laboratory parameters that were initially abnormal returned to normal values. On day 14, he was discharged without any neurological complications.