Severe long term chronic complications of neuroleptic malignant syndrome: a case report (original) (raw)

A ‘benign’ extrapyramidal side effect masking a life-threatening neuroleptic malignant syndrome

Pakistan Journal of Medical Sciences, 2020

The neuroleptic malignant syndrome is a rare, life-threatening idiosyncratic reaction to neuroleptic medication. The use of newer antipsychotics combined with its rare incidence has made NMS seem as a complication of the past. Here we report a patient in his early 20s suffering from a psychotic disorder developing a life-threatening neuroleptic malignant syndrome on an inpatient psychiatric ward in Canada without the characteristic overt change in autonomic stability. We review the clinical characteristics to facilitate the early recognition of neuroleptic malignant syndromes and discuss why this condition still is highly relevant for practising physicians. doi: https://doi.org/10.12669/pjms.36.6.2963 How to cite this:Dolp R, Ansari MA, Chan M, Hassan T. A ‘benign’ extrapyramidal side effect masking a life-threatening neuroleptic malignant syndrome. Pak J Med Sci. 2020;36(6):1429-1432. doi: https://doi.org/10.12669/pjms.36.6.2963 This is an Open Access article distributed under the ...

The treatment and management of neuroleptic malignant syndrome

Progress in Neuro-Psychopharmacology and Biological Psychiatry, 1992

In cases of severe EPS with fever greater than or equal to 101, we recommend stopping neuroleptlcs, treating with anticholinergics and starting with dopamine agonists. In the event of a poor response to dopamine agonists, a brief trial of dantrolene and/or benzodiazepines is recoanaended. Oantrolene should not be introduced for prolonged periods, since abnormal liver function studies have been observed in approximately 1.8% of patients. In cases of extreme hyperpyrexia (fever greater than 103). clinicians should consider transfer to an ICU or another medical support. Extreme temperatures have been associated with potentially irreversible cerebellar or other brain damage, if not aggressively treated. If neuroleptics are later indicated, a 2 week interval after resolution of symptoms should be maintained before reinstituting neuroleptics. In patients with severe EPS without fever, we emphasize aggressive use of anticholinergic therapy, while simultaneously considering the psychiatric need for neuroleptics versus medical risks. In all cases where a patient's swallowing, respirations or physical mobility is severely compromised, we suggest stopping neuroleptics. Anticholinergic agents should be continued for 7 days after neuroleptics are stopped. If ant~cholinergic agents are unsuccessful after 2-3 dosages, dopamine agonists may be added, while simultaneously monitoring vital signs. It should be emphasized that severe EPS sometimes takes days to improve even after neuroleptic cessation and the addition of anticholinergics. If EPSs are intense or of long enough duration and, particularly, in the presence of akathisia and agitation, then a combination of excess heat production and interference wfth the hypothalamic temperature control mechanisms can produce a syndrome of NMS. If EPSs are avoided, neuroleptics are used in low dosages and benzodiazepfnes are used concomitantly for agitation, then we should see very little of NMS.

Neuroleptic malignant syndrome

Arquivos de Neuro-Psiquiatria, 2011

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.

Neuroleptic Malignant Syndrome – A medical emergency in a psychiatric patient

Bangladesh Critical Care Journal

With an estimated incidence of 0.02 to 3.23%1, neuroleptic malignant syndrome (NMS) is a rare idiosyncratic reaction to antipsychotic drugs; having a relatively high fatality rate of about 10%2. Here, we are reporting, a 38 years old female schizoaffective patient, presented with fever, muscle rigidity and altered sensorium who had started tablet risperidone(an atypical antipsychotic drug) 11 days prior to hospital admission. After initial sepsis work up and neuroimaging, infective causes and acute cerebrovascular incidents were ruled out and a presumptive diagnosis of NMS was made. Immediate discontinuation of suspected causative agent, along with the provision of supportive care leads to complete resolution of all the symptoms in our patient.Bangladesh Crit Care J September 2018; 6(2): 108-110

Resolution of symptoms in neuroleptic malignant syndrome

Indian Journal of Psychiatry, 2010

a 56-year-old married male, was diagnosed as a case of schizophrenia 30 years back. He was hospitalized thrice for exacerbations of his illness and he was initiated on anti-psychotics and electroconvulsive therapy (ECT). He was maintaining well on tablet (tab) chlorpromazine 150 mg/day for 10 years and tab clozapine 200 mg/day since 3 years. He was also receiving tab atenolol 50 mg a day for hypertension for the last 15 years. Mr. S.D. was admitted to our hospital with a 1-week history of sleep disturbances, poor communication with family members, tremulousness of hands, excessive sweating, slurred speech, and urinary incontinence. On mental status examination, he was found to have catatonic symptoms and was hallucinating. His physical examination showed tachycardia, mild dehydration, tremors of both hands, cogwheel rigidity in all four limbs, grade V power, normal deep tendon reflexes, and flexor plantar reflexes bilaterally. He had no signs of meningeal irritation or any cerebellar deficit. A provisional diagnosis of NMS was made, clozapine and chlorpromazine were stopped, and the patient was initiated on parenteral lorazepam 2 mg every 12 hours. On the second day, the patient's temperature was found to be 102°F and the creatinine phosphokinase (CPK) level was 396 IU/L. He was transferred to the medical ward. On the third day he was found to be having tachypnea and hypotension. His CPK level was now 1271 IU/L; the total leucocyte count 10400/mm 3 and hemoglobin was 8.8 gm/dL; the ESR, renal and liver function tests, serum electrolytes, and cerebospinal fluid analysis were within normal limits. He was started on tab bromocriptine 2.5 mg twice a day along with intravenous fluids and antibiotics.

Diagnostic and therapeutic challenges in neuroleptic malignant syndrome: a severe medical case

Rivista di psichiatria, 2020

Neuroleptic malignant syndrome (NMS) is a rare, idiosyncratic medical emergency usually associated with the use of dopamine antagonists, commonly typical antipsychotic drugs. However, it has been observed that it can occur with atypical antipsychotics as well. NMS is characterized by altered consciousness, fever, rigidity, autonomic instability and high creatine phosphokinase (CPK) blood levels. Here, we report a case of a 44-year-old female patient with history of a treatment-resistant bipolar disorder. She was admitted to our psychiatric ward for severe psychomotor agitation and treated with a therapy based on typical and atypical antipsychotics. During the course of the hospitalization she developed NMS. In this case, the diagnosis was delayed due to the slow and insidious symptom presentation, therefore requiring a differential diagnosis. Autoimmune NMDA receptor encephalitis, catatonic syndrome and malignant catatonia have been excluded. The patient met all the DSM-5 criteria f...

Neuroleptic-Induced Extrapyramidal Symptoms With Fever

Archives of General Psychiatry, 1986

\s=b\From 39 reported cases of the "neuroleptic malignant syndrome," three groups were identified: those with concurrent medical problems that could cause fever that accompanied the extrapyramidal symptoms; those with medical problems less clearly related to fever; and those without other medical disorders. Dehydration, infection, pulmonary embolus, and rhabdomyolysis were the common complications of untreated extrapyramidal symptoms. Three patients died, all with medical complications. In 14 cases, no medical cause of fever was identified. Hypotheses about mechanisms for fever include psychiatric illness, disruption of dopaminergic aspects of thermoregulation, and peripheral and central effects on muscle contraction leading to excess heat production. Neuroleptic-induced rigidity should be treated vigorously, with prompt discontinuation of neuroleptic therapy and administration of dopamine agonists in severe cases with or without fever. The cases of extrapyramidal symptoms with fever are too heterogeneous to justify the assumption of a unitary and "malignant" syndrome.

Neuroleptic malignant syndrome: a guide for psychiatrists

BJPsych Advances, 2020

SUMMARY Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse reaction to drugs. In psychiatric practice, it is mainly associated with antipsychotics. The classic presentation is that of hyperpyrexia, muscle rigidity, mental state changes and autonomic instability. Subtle forms are difficult to recognise owing to symptom overlap with other conditions. This article discusses the clinical presentation of the syndrome, its differential diagnosis and use of supportive care, medication and electroconvulsive therapy in its treatment. It also explores prevention of NMS and reinstatement of treatment after an episode. It is stressed that all but the mildest forms of NMS should be considered a medical emergency that is properly managed in an acute hospital.