Can Neutrophil-Lymphocyte Ratio Be a Useful Criterion for Neuroleptic Malignant Syndrome in the Absence of Leukocytosis?

Objective: Neuroleptic malignant syndrome (NMS) is a rare but severe side effect of antipsychotic medication. Neutrophil-lymphocyte ratio (NLR) is a simple marker used to measure systemic inflammation. Method : In this case report we explore the relationship of inflammation in the etiology of NMS. In our case involving NMS, although there was no leukocytosis, the NLR was increased up to systemic infection levels. Conclusion: We hypothesized that systemic inflammation may take a role in developing NMS. If so, NLR could be a new marker of NMS that may be able to provide more sensitive results than leukocyte levels.

Slow your role: How slowing clozapine titration can prevent recurrent NMS

Ms. D. was a 57-year-old Caucasian female with a past psychiatric history of schizoaffective disorder bipolar type and unspecified anxiety disorder. She presented to the psychiatric unit with cognitive blunting, poverty of thought content, looseness of associations, and inability to respond to questions with meaningful responses. In addition, the patient presented with medical symptoms including rigidity, acute rhabdomyolysis, and elevated liver function tests (LFTs). She was transferred to the inpatient medical unit for stabilization. After acute stabilization, she was transferred back to the psychiatric unit for treatment. A thorough review of the patient's history revealed she had prior episodes of atypical NMS with trials of multiple typical and atypical antipsychotics at therapeutic doses and with clinically appropriate titration schedules. These trials included clozapine, which is known to have decreased likelihood of NMS symptoms. The patient was stabilized during admission, but later decompensated and required re-admission in the months following. At that time, clozapine was reinstituted at very low doses and with a slower titration schedule. This approach was successful in ameliorating the patient's symptoms and without recurrence of NMS. In this case report, we discuss the importance of identifying atypical NMS in patients treated with typical and atypical antipsychotics, and propose that successful treatment of these patients may be possible with slower and gradual titration of clozapine.

Neuroleptic Malignant Syndrome Associated with Lithium Toxicity

Neuroleptic Malignant Syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction to neuroleptic drugs. Lithium is a first-line mood stabilizer used in the treatment and prophylaxis of bipolar disorder. There are several case reports of lithium-associated NMS, but only when it was given in combination with antipsychotics. Therefore, the possibility of NMS being secondary to the antipsychotics could not be ruled out in those cases. Here we present a case of lithium-induced NMS in a patient who was not being treated concomitantly with any other agent known to cause NMS. The patient, a 74-year-old female with a 30-year history of bipolar affective disorder, was admitted to the emergency room of the All India Institute of Medical Sciences, New Delhi, with history of high fever and generalized weakness for 10 days before the admission. NMS was established based the presence of three cardinal symptoms. She was started on intravenous fluids to correct her sodium levels slowly and requested to follow-up at the psychiatry clinic.

Is it anger reaction before discharge?

Delirium and neuroleptic malignant syndrome (NMS) are two uncommon syndromes that are often unrecognized or misdiagnosed by the primary physicians as functional psychiatric disorders. The infrequency and the heterogeneity of clinical manifestation, progression and outcome with which those diagnoses are encountered (particularly in chronic rehabilitation settings) make them formidable diagnostic challenge. In this report, we present a case in which there was a misdiagnosis of delirium and NMS as functional psychiatric disorders. This report demonstrates the fact that early recognition and intervention in such cases are essential to prevent the grave outcome and potential fatality. The authors believe that there is a key role for the consulting psychiatrist in this area in providing diagnostic clarity and advice regarding management and ongoing staff education.

Occurrence of neurolepric malignant syndrome on trihexphenidyl discontinuation

The neuroleptic malignant syndrome (NMS) commonly occurs on treatment with neuroleptics, it is also reported in patients who suddenly stop drugs like levodopa, amitriptyline and imipramine. We report a case of NMS, which occurred in a patient on lithium, haloperidol and trihexyphenidyl (THP) after sudden discontinuation of THP. The cholinergic system, through its effect on the dopaminergic system, may play a role in the genesis of NMS. Alternatively, anticholinergic withdrawal may produce extrapyramidal symptoms (EPS), and the consequent alteration in food and fluid intake may produce electrolyte imbalance which increases the risk for NMS.

The neuroleptic malignant syndrome : report of three cases

Three patients, one male and two females who developed neuroleptic malignant syndrome following exposure to depot and oral neuroleptic are presented. The patients satisfied Levenson's criteria for diagnosis. Bromocriptine and Electro Convulsive Therapy were found effective whereas trihexyphenidyl proved unsatisfactory in the treatment. All the patients recovered completely without complications.