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Kutumbaka T, Varadan S, Sudagar Singh RB. The Atypical Face of Neuroleptic Malignant Syndrome: A Case Report of Ileus and Absent Rigidity. Cureus 2024; 16:e63784. [PMID: 39099918 PMCID: PMC11297847 DOI: 10.7759/cureus.63784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/06/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare life-threatening condition associated with the use of antipsychotic medications. This case report describes a male patient in his early 30s who presented with fever, breathlessness, and lower limb weakness, ultimately diagnosed with NMS despite the absence of muscular rigidity. On examination, he was febrile, tachycardic, and tachypneic with an oxygen saturation of 88% and elevated blood pressure. On auscultation diffuse crepitations in both lungs were revealed. Neurological assessment indicated motor strength of 3/5 in both lower limbs, without rigidity, sensory loss, or cerebellar signs. It was noted that he was on irregular atypical antipsychotic medication for the past one year. Laboratory investigations revealed leukocytosis, elevated transaminases, dyselectrolytemia, elevated creatine phosphokinase (CPK), and serum creatinine. NMS was not initially considered due to the lack of muscular rigidity. However, the patient later developed autonomic dysregulation manifestations, such as paralytic ileus. Once organic causes were excluded, NMS was diagnosed. Supportive therapy included 23 cycles of hemodialysis and colonic decompression for pseudo-obstruction. He was treated with intravenous fluids and dopamine receptor agonist medications. NMS usually presents with fever, muscular rigidity, altered mental status, and autonomic instability; yet, the absence of muscular rigidity in this patient is a distinctive and unusual feature.
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Affiliation(s)
- Tarun Kutumbaka
- General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Sivaprakash Varadan
- General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - R B Sudagar Singh
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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2
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Sweileh WM. Neuroleptic malignant syndrome and serotonin syndrome: a comparative bibliometric analysis. Orphanet J Rare Dis 2024; 19:221. [PMID: 38825678 PMCID: PMC11145872 DOI: 10.1186/s13023-024-03227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/27/2024] [Indexed: 06/04/2024] Open
Abstract
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.
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Affiliation(s)
- Waleed M Sweileh
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine.
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3
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Nakamura S, Iida A, Tsukahara K, Naito H. Successful Diagnosis of Neuroleptic Malignant Syndrome in an Unconscious Patient Using Amplitude-Integrated Electroencephalography: A Case Report. Cureus 2024; 16:e61927. [PMID: 38978900 PMCID: PMC11228452 DOI: 10.7759/cureus.61927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/10/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare but life-threatening medical condition often characterized by altered consciousness and clinical features resembling seizures. This case report presents a unique and successful diagnosis of NMS in an unconscious patient with an unknown medical history. We demonstrate the potential utility of amplitude-integrated electroencephalography (aEEG) as a valuable tool for the differential diagnosis of seizure-like medical conditions, including NMS. The application of aEEG allowed for early diagnosis and prompt initiation of appropriate treatment, potentially contributing to improved patient outcomes.
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Affiliation(s)
- Shunsuke Nakamura
- Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, JPN
| | - Atsuyoshi Iida
- Advanced Emergency and Critical Care Center, Okayama University Hospital, Okayama, JPN
| | - Kohei Tsukahara
- Advanced Emergency and Critical Care Center, Okayama University Hospital, Okayama, JPN
| | - Hiromichi Naito
- Advanced Emergency and Critical Care Center, Okayama University Hospital, okayama, JPN
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Truedson P, Ott M, Wahlström L, Lundqvist R, Maripuu M, Lindmark K, Lieber I, Werneke U. Serious adverse drug events associated with psychotropic treatment of bipolar or schizoaffective disorder: a 17-year follow-up on the LiSIE retrospective cohort study. Front Psychiatry 2024; 15:1358461. [PMID: 38633030 PMCID: PMC11022285 DOI: 10.3389/fpsyt.2024.1358461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/07/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Mood stabilisers and other psychotropic drugs can lead to serious adverse drug events (ADEs). However, the incidence remains unknown. We aimed to (a) determine the incidence of serious ADEs in patients with bipolar or schizoaffective disorders, (b) explore the role of lithium exposure, and (c) describe the aetiology. Methods This study is part of the LiSIE (Lithium-Study into Effects and Side Effects) retrospective cohort study. Between 2001 and 2017, patients in the Swedish region of Norrbotten, with a diagnosis of bipolar or schizoaffective disorder, were screened for serious ADEs to psychotropic drugs, having resulted in critical, post-anaesthesia, or intensive care. We determined the incidence rate of serious ADEs/1,000 person-years (PY). Results In 1,521 patients, we identified 41 serious ADEs, yielding an incidence rate of 1.9 events per 1,000 PY. The incidence rate ratio (IRR) between ADEs with lithium present and causally implicated and ADEs without lithium exposure was significant at 2.59 (95% CI 1.20-5.51; p = 0.0094). The IRR of ADEs in patients <65 and ≥65 years was significant at 3.36 (95% CI 1.63-6.63; p = 0.0007). The most common ADEs were chronic lithium intoxication, oversedation, and cardiac/blood pressure-related events. Discussion Serious ADEs related to treatment of bipolar (BD) or schizoaffective disorder (SZD) were uncommon but not rare. Older individuals were particularly at risk. The risk was higher in individuals exposed to lithium. Serum lithium concentration should always be checked when patients present with new or unclear somatic symptoms. However, severe ADEs also occurred with other mood stabilisers and other psychotropic drugs.
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Affiliation(s)
- Petra Truedson
- Department of Clinical Sciences, Psychiatry, Sunderby Research Unit, Umeå University, Umeå, Sweden
| | - Michael Ott
- Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden
| | - Lisa Wahlström
- Department of Psychiatry, Sunderby Hospital, Luleå, Sweden
| | - Robert Lundqvist
- Department of Public Health and Clinical Medicine, Sunderby Research Unit, Umeå University, Luleå, Sweden
| | - Martin Maripuu
- Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Lieber
- Department of Clinical Sciences, Psychiatry, Sunderby Research Unit, Umeå University, Umeå, Sweden
| | - Ursula Werneke
- Department of Clinical Sciences, Psychiatry, Sunderby Research Unit, Umeå University, Umeå, Sweden
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Farrugia S, Bonello S, Gatt Y, Balzan MV. Atypical Neuroleptic Malignant Syndrome With Type 2 Respiratory Failure Treated With Non-invasive Ventilation. Cureus 2024; 16:e51878. [PMID: 38327911 PMCID: PMC10849262 DOI: 10.7759/cureus.51878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 02/09/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is characterized by hyperthermia, severe rigidity, and autonomic instability that is life-threatening if not treated promptly by intensive supportive care. However, there have been numerous reports of "atypical NMS" where the diagnostic criteria of NMS are only partially satisfied. We present a case of an elderly male who presented with atypical NMS secondary to antidopaminergic drug administration which precipitated acute respiratory failure. Our patient exhibited features of severe rigidity and autonomic instability, without hyperthermia. He developed tachypneic hypoventilation with type 2 hypercapneic respiratory failure which was treated with non-invasive ventilation (NIV). The patient recovered after three days with resolution of rigidity and was transferred to a normal medical ward on oxygen via a facemask, where he gradually improved. This study highlights that non-invasive ventilation may have a role in treating respiratory failure in mild to moderate cases of atypical NMS, avoiding the need for intubation.
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Affiliation(s)
| | - Sarah Bonello
- Respiratory Medicine, Mater Dei Hospital, Msida, MLT
| | - Yanika Gatt
- Respiratory Medicine, Mater Dei Hospital, Msida, MLT
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Bhargava S, Bairwa K, Motwani Y. Neuroleptic malignant syndrome after abrupt discontinuation of neuroleptic and anticholinergic drugs. Ind Psychiatry J 2023; 32:S277-S278. [PMID: 38370948 PMCID: PMC10871422 DOI: 10.4103/ipj.ipj_207_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/31/2023] [Accepted: 08/12/2023] [Indexed: 02/20/2024] Open
Affiliation(s)
- Sameer Bhargava
- Department of Psychiatry, JNUIMSRC, Jaipur, Rajasthan, India
| | - Khushboo Bairwa
- Department of Psychiatry, JNUIMSRC, Jaipur, Rajasthan, India
| | - Yogesh Motwani
- Department of Psychiatry, JNUIMSRC, Jaipur, Rajasthan, India
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Isik AT, Kaya D, Ontan MS, Mutlay F, Bulut EA, Dost FS, Erken N, Aydin AE. Neuroleptic Malignant Syndrome in Patients With Dementia: Experiences of A Single Memory Clinic. Clin Neuropharmacol 2023; 46:209-213. [PMID: 37962307 DOI: 10.1097/wnf.0000000000000570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
OBJECTIVES Neuroleptic malignant syndrome (NMS) is a life-threatening condition that occurs as an adverse reaction to antipsychotic and antiemetic agents or sudden withdrawal of dopaminergic medications. Given the metabolic and functional reserves and the comorbidities in older adults, NMS may show an atypical course. METHODS The medical records of patients with neurodegenerative diseases leading to dementia between 2013 and 2020 were reviewed for the diagnosis of NMS. Demographic and clinical characteristics of the patients were obtained from the records of laboratory parameters, management, and length of stay. RESULTS Fifteen older adults (19 episodes) diagnosed with NMS were included. The median age was 76 years, and 5 were female. Ten of 15 NMS patients were atypical. Most of them had an infection accompanying NMS. Neuroleptic malignant syndrome was caused by antidopaminergic agents (5 antipsychotics, 1 metoclopramide) in 6 episodes and discontinuation of a dopaminergic agent, l -DOPA, in 12 episodes. In 1 patient, it was associated with simultaneous use of domperidone and amantadine withdrawal. Rigidity in NMS due to l -DOPA discontinuation was higher than in those due to antipsychotic use ( P = 0.027). Two of our patients needed intensive care, and 1 died. CONCLUSIONS This study highlights the high frequency of atypical NMS and the importance of early recognition of this potentially fatal syndrome, which can accompany neurodegenerative diseases and infections in older adults.
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Affiliation(s)
- Ahmet Turan Isik
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir
| | - Derya Kaya
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir
| | - Mehmet Selman Ontan
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir
| | - Feyza Mutlay
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir
| | - Esra Ates Bulut
- Department of Geriatric Medicine, Adana City Research and Training Hospital, Adana
| | - Fatma Sena Dost
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir
| | - Neziha Erken
- Department of Geriatric Medicine, University of Gazi Antep, Gaziantep
| | - Ali Ekrem Aydin
- Department of Geriatric Medicine, Sivas Numune Hospital, Sivas, Turkey
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8
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Pàmpols-Pérez S, Gisbert-Solà A, Resa-Pérez B, Jiménez-Mayoral A, Forcada-Pach I, Llorca-Bofi V. Neuroleptic Malignant Syndrome Associated With Lurasidone: A Case Report. J Clin Psychopharmacol 2023; 43:548-549. [PMID: 37930214 DOI: 10.1097/jcp.0000000000001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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Jan MZH, Figgs P, Gallucci G, Bacchus R. COVID-19 Pandemic-Delayed Diagnosis and Treatment of Atypical Neuroleptic Malignant Syndrome in a Violent Forensics Patient With Intellectual Disability and Treatment-Resistant Schizophrenia. Cureus 2023; 15:e41866. [PMID: 37581140 PMCID: PMC10423458 DOI: 10.7759/cureus.41866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
This case report highlights an episode of neuroleptic malignant syndrome (NMS) in a forensic psychiatry inpatient unit and how the coronavirus disease (COVID) pandemic, as well as, an atypical presentation of NMS delayed diagnosis and treatment of a patient, which could have been fatal. NMS and atypical NMS manifest typically after the use of anti-psychotics during the first two weeks of initiation of treatment. COVID can mimic many of the initial symptoms of NMS such as changes in mental status, fever, and, at times, dysautonomia. This case will try and highlight why this crossover of symptoms and the forensic environment made diagnosis and treatment in this particular case more difficult.
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Affiliation(s)
| | - Patricia Figgs
- Psychiatry and Behavioral Sciences, The Delaware Psychiatric Center, New Castle, USA
| | - Gerard Gallucci
- Psychiatry, The Delaware Psychiatric Center, New Castle, USA
| | - Romona Bacchus
- Psychiatry, The Delaware Psychiatric Center, New Castle, USA
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10
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Hölle T, Purrucker JC, Morath B, Weigand MA, Schmitt FCF. [Central anticholinergic, neuroleptic malignant and serotonin syndromes]. WIENER KLINISCHES MAGAZIN : BEILAGE ZUR WIENER KLINISCHEN WOCHENSCHRIFT 2023; 26:124-132. [PMID: 37251531 PMCID: PMC10123475 DOI: 10.1007/s00740-023-00492-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.
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Affiliation(s)
- Tobias Hölle
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Jan C. Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Benedict Morath
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A. Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Felix C. F. Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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11
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Hölle T, Purrucker JC, Morath B, Weigand MA, Schmitt FCF. [Central anticholinergic, neuroleptic malignant and serotonin syndromes : Important differential diagnoses in postoperative impairment of consciousness]. DIE ANAESTHESIOLOGIE 2023; 72:157-165. [PMID: 36799968 PMCID: PMC9936123 DOI: 10.1007/s00101-023-01256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 02/18/2023]
Abstract
Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.
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Affiliation(s)
- Tobias Hölle
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Jan C. Purrucker
- grid.5253.10000 0001 0328 4908Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Benedict Morath
- grid.5253.10000 0001 0328 4908Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A. Weigand
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Felix C. F. Schmitt
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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12
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Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Zhao H, Lu S, Li X, Huang P, Wang H, Lu F. Multidisciplinary collaboration in diagnosis and treatment of neuroleptic malignant syndrome complicated with pneumonia: report of three cases. Diagn Pathol 2022; 17:89. [DOI: 10.1186/s13000-022-01270-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Neuroleptic malignant syndrome (NMS) is a relatively rare and a potentially fatal syndrome. It is a serious complication associated with antipsychotic therapy. NMS is easily prone to pneumonia, rhabdomyolysis and other problems. However, the clinical features of NMS complicated with pneumonia remains largely unclear.
Case presentation
Here, we described three female adult patients of NMS complicated with pneumonia in our own hospital. The symptoms of the patients were controlled with antipsychotic drugs at admission. Symptoms such as high fever, high muscle tone, difficulty in eating, phlegm in the throat, anhelation, rhabdomyolysis and autonomic nervous dysfunction occurred 2 days after the treatment, which mainly concentrated within 1 week. In addition, they are all healed.
Conclusions
NMS is a rare and serious complication in psychiatric department, which is easy to be complicated with pneumonia and respiratory failure. Timely identification and early intervention could help achieve a good prognosis.
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Caroff SN, Roberts CB, Rosenberg H, Tobin JR, Watt S, Mashman D, Riazi S, Berkowitz RM. Intravenous dantrolene in hypermetabolic syndromes: a survey of the U.S. Veterans Health Administration database. BMC Anesthesiol 2022; 22:298. [PMID: 36123618 PMCID: PMC9484236 DOI: 10.1186/s12871-022-01841-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous dantrolene is often prescribed for hypermetabolic syndromes other than the approved indication of malignant hyperthermia (MH). To clarify the extent of and indications for dantrolene use in conditions other than MH, we sought to document current practices in the frequency, diagnoses, clinical characteristics and outcomes associated with dantrolene treatment in critical care settings. METHODS Inpatients receiving intravenous dantrolene from October 1, 2004 to September 30, 2014 were identified retrospectively in the U.S. Veterans Health Administration national database. Extracted data included; diagnoses of hypermetabolic syndromes; triggering drugs; dantrolene dosages; demographics; vital signs; laboratory values; in-hospital mortality; complications; and lengths of stay. Frequency and mortality of patients who did not receive dantrolene were obtained in selected diagnoses for exploratory comparisons. RESULTS Dantrolene was administered to 304 inpatients. The most frequent diagnoses associated with dantrolene treatment were neuroleptic malignant syndrome (NMS; N = 108, 35.53%) and sepsis (N = 47, 15.46%), with MH accounting for only 13 (4.28%) cases. Over half the patients had psychiatric comorbidities and received psychotropic drugs before dantrolene treatment. Common clinical findings in patients receiving dantrolene included elevated temperature (mean ± SD; 38.7 ± 1.3 °C), pulse (116.33 ± 22.80/bpm), respirations (27.75 ± 9.58/min), creatine kinase levels (2,859.37 ± 6,646.88 IU/L) and low pO2 (74.93 ± 40.16 mmHg). Respiratory, renal or cardiac failure were common complications. Mortality rates in-hospital were 24.01% overall, 7.69% in MH, 20.37% in NMS and 42.55% in sepsis, compared with mortality rates in larger and possibly less severe groups of unmatched patients with MH (5.26%), NMS (6.66%), or sepsis (41.91%) who did not receive dantrolene. CONCLUSIONS In over 95% of cases, dantrolene administration was associated with diagnoses other than MH in critically-ill patients with hypermetabolic symptoms and medical and psychiatric comorbidities. Exploratory survey data suggested that the efficacy and safety of dantrolene in preventing mortality in hypermetabolic syndromes other than MH remain uncertain. However, randomized and controlled studies using standardized criteria between groups matched for severity are essential to guide practice in using dantrolene.
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Affiliation(s)
- Stanley N Caroff
- Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Henry Rosenberg
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | | | | | - Darlene Mashman
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Rosalind M Berkowitz
- Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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15
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Síndrome neuroléptico maligno asociado con intoxicación aguda por un organofosforado: reporte de caso. BIOMÉDICA 2022; 42:445-449. [PMID: 36122284 PMCID: PMC9552747 DOI: 10.7705/biomedica.6428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Indexed: 12/02/2022]
Abstract
El síndrome neuroléptico maligno es una condición clínica rara y potencialmente letal que frecuentemente se asocia con el uso de antipsicóticos. En la literatura especializada se encontró únicamente un reporte de caso relacionado con la ingestión de organofosforados. Se presenta un paciente con un cuadro clínico correspondiente al síndrome neuroléptico maligno posterior a la ingestión de clorpirifós. Como resultado de un intento de suicidio con el mencionado organofosforado, el hombre de 57 años presentó deterioro agudo del estado de consciencia, evolución neurológica tórpida e inestabilidad autonómica asociada a rigidez e hipertermia persistentes, así como incremento de la creatina-fosfocinasa (creatine phosphokinase, CPK). Se le administró tratamiento con bromocriptina, con lo cual el cuadro clínico remitió, y fue dado de alta sin secuelas. El diagnóstico del síndrome neuroléptico maligno es clínico y debe contemplarse en cualquier caso de exposición a sustancias que puedan resultar en una desregulación de la neurotransmisión dopaminérgica, con el fin de iniciar el tratamiento oportuno y contrarrestar efectivamente los efectos.
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Fervienza A, López-Baamonde M, Jacas A, Muñoz G, Ibáñez C, Del Rio ME. Neuroleptic malignant syndrome in a postoperative patient: A case report. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:364-367. [PMID: 35753931 DOI: 10.1016/j.redare.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/28/2020] [Indexed: 06/15/2023]
Abstract
Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis. A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity. Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms. The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.
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Affiliation(s)
- A Fervienza
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, Spain.
| | | | - A Jacas
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, Spain
| | - G Muñoz
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, Spain
| | - C Ibáñez
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, Spain
| | - M E Del Rio
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, Spain
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Lin Y, Ma L, Zhang N, Li R, Jiang W. Neuroleptic malignant-like syndrome associated multiple system atrophy: report on three cases. BMC Neurol 2022; 22:67. [PMID: 35216572 PMCID: PMC8876065 DOI: 10.1186/s12883-022-02583-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Multiple system atrophy (MSA) associated with neuroleptic malignant-like syndrome (NMLS) is rare and few cases have been described in the literature. Case presentation In the present study, three patients with MSA associated with NMLS were analyzed from January 2012 to January 2020 to characterize their clinical presentations. Data collected from the patients for analysis included general patient history, the fluctuation and severity of disease symptoms, the indicated therapies and disease progression at follow-up. All patients had histories of sudden withdrawal or reduction of levodopa prior to the onset of symptoms. Clinical presentations were characterized by hyperthermia, autonomic dysfunction, worsening of extrapyramidal symptoms, and elevated serum creatine kinase (CK) levels. During hospitalization, one patient rapidly progressed and died, while the other two patients were successfully treated. Conclusions Early diagnosis and treatment are very important for patient outcomes in NMLS. Notably, the correct dose and time of administration of dopaminergic medication may be key in treating NMLS. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02583-8.
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Affiliation(s)
- Yan Lin
- Department of Geriatric Medicine and Shandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Lin Ma
- Department of Geriatric Medicine and Shandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Nan Zhang
- Department of Geriatric Medicine and Shandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Ruihua Li
- Department of Geriatric Medicine and Shandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Wenjing Jiang
- Department of Geriatric Medicine and Shandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China. .,Shandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China.
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Touzani S, Hamdouni M, Houari N, Khbiza YY, Elbouazzaoui A, Boukatta B, Kanjaa N. Neuroleptic malignant syndrome cases in a Moroccan intensive care unit: a retrospective analysis and literature review. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening neuropsychiatric emergency. The aim of our study was to update our bedside procedures by investigating NMS cases managed in the intensive care unit (ICU).Methods: This retrospective study included all NMS patients admitted to our hospital between January 2012 and December 2019. The variables analyzed included demographics, diagnosis, therapeutics, and outcomes.Results: This study included 20 patients, with an average age of 36.6 years. The male to female ratio was 1:4. No patient had a history of NMS, and 60% of the patients had schizophrenia. First-generation neuroleptics (NLs) were the most commonly prescribed drugs (80%). The mean time between the introduction of NLs and onset of symptoms was 7.6 days. Rigidity was observed in 90% of the patients, hyperthermia and neuropsychic syndrome in 65%, and dysautonomia in 50%. The creatine phosphokinase level in all patients was four times the normal value. Mechanical ventilation was required in 20% of the patients and hemodialysis in one patient. None of the patients received specific therapy. The mean duration of ICU stay was 10 days. The mortality rate was 10%,, mainly associated with renal failure. The analysis of the predictors of mortality was limited by the size of our cohort.Conclusion: NMS is a rare condition requiring multidisciplinary implementation of contextualized and updated procedures. Early detection and supportive treatment could improve the prognosis in resource-limited settings, where specific treatments are not available. Predictive risk factors should be investigated in larger multicenter cohorts.
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Joseph S, George J, Tau M, Ibanez-Valdes LDF, Dubula T, Foyaca-Sibat H. Case Report: Neuroleptic malignant syndrome in a HIV-positive patient. F1000Res 2021; 9:1382. [PMID: 36072922 PMCID: PMC9396113 DOI: 10.12688/f1000research.27165.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/20/2022] Open
Abstract
We report a 29-year-old, HIV-positive woman being treated with antipsychotic medication for psychosis (Clopixol 200mg intramuscularly monthly, Risperidone 2mg orally daily Haloperidol 2.5mg twice a day), who presented with neuroleptic malignant syndrome. She was also receiving lorazepam and sodium valproate. The patient was referred to our department as she had developed involuntary upper limb movements and simple permanent focal seizure on the lower part of the left hemiface. Clinically the patient had altered consciousness, autonomic dysfunction, and rigidity. Her blood tests showed elevated creatine kinase (1467U/L) but no leucocytosis. We did a thorough workup for other causes of such a presentation. A comprehensive history was taken from the family to exclude other medications used. Her cerebrospinal fluid results were average. Blood tests did not show evidence of infection or other abnormalities. Computed tomography brain was normal. The patient died a few days after the beginning of the attack, which we have also observed in other HIV-female patients. As far as we know, it is the first report about this comorbidity reported in the medical literature.
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Affiliation(s)
- Sibi Joseph
- Department of Neurology, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Jerry George
- Department of Neurology, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Mongezi Tau
- Department of Internal Medicine, Walter Sisulu University/Nelson Mandela Academic Hopsital, Mthatha, Eastern Cape, 5100, South Africa
| | - Lourdes de Fatima Ibanez-Valdes
- Department of Neurology, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Thozama Dubula
- Department of Internal Medicine, Walter Sisulu University/Nelson Mandela Academic Hopsital, Mthatha, Eastern Cape, 5100, South Africa
| | - Humberto Foyaca-Sibat
- Department of Neurology, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
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León-Amenero D, Huarcaya-Victoria J. Neuroleptic malignant syndrome in children and adolescents: Systematic review of case reports. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 50:290-300. [PMID: 34742696 DOI: 10.1016/j.rcpeng.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal drug adverse reaction. There are still few studies of this entity in the child-adolescent population. OBJECTIVES Describe the clinical, laboratory and therapeutic characteristics of children and adolescent patients with NMS. Analyse the grouping of symptoms present in NMS in the same population. MATERIAL AND METHODS A MEDLINE/PubMed search of all reported cases of NMS from January 2000 to November 2018 was performed and demographic, clinical, laboratory and therapeutic variables were identified. A factorial analysis of the symptoms was performed. RESULTS 57 patients (42 males and 15 females) were included, (mean age 13.65 ± 3.89 years). The onset of NMS occurred at 11.25 ± 20.27 days with typical antipsychotics and at 13.69 ± 22.43 days with atypical antipsychotics. The most common symptoms were muscle stiffness (84.2%), autonomic instability (84.2%) and fever (78.9). The most common laboratory findings were CPK elevation and leucocytosis (42.1%). The most used treatment was benzodiazepines (28.1%). In the exploratory factorial analysis of the symptoms we found 3 factors: 1) "Catatonic" with mutism (0.912), negativism (0.825) and waxy flexibility (0.522); 2) "Extrapyramidal" with altered gait (0.860), involuntary abnormal movements (0.605), muscle stiffness (0.534) and sialorrhoea (0.430); and 3) "Autonomic instability" with fever (0.798), impaired consciousness (0.795) and autonomic instability (0.387). CONCLUSIONS NMS in children and adolescents could be of 3 types: catatonic, extrapyramidal and autonomic unstable.
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Affiliation(s)
- Deborah León-Amenero
- Médico psiquiatría de niños y adolescentes, Servicio de Psiquiatría Infanto-juvenil, Departamento de Psiquiatría, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Jeff Huarcaya-Victoria
- Universidad de San Martín de Porres, Facultad de Medicina, Centro de Investigación en Salud Pública, Lima, Peru; Médico psiquiatra, Servicio de Psiquiatría General, Departamento de Psiquiatría, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.
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Guinart D, Misawa F, Rubio JM, Pereira J, de Filippis R, Gastaldon C, Kane JM, Correll CU. A systematic review and pooled, patient-level analysis of predictors of mortality in neuroleptic malignant syndrome. Acta Psychiatr Scand 2021; 144:329-341. [PMID: 34358327 DOI: 10.1111/acps.13359] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/12/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Neuroleptic malignant syndrome (NMS) is a potentially fatal, idiosyncratic reaction to antipsychotics. Due to low incidence of NMS, research on risk factors of mortality associated with NMS is limited. METHODS Two authors independently searched Medline/Embase/Cochrane/CINAHL/PsychINFO databases for case reports with author-defined NMS published in English until 05/30/2020. Demographic, clinical, treatment, and outcome data were independently extracted following PRISMA guidelines. NMS severity was rated using the Francis-Yacoub scale. Mortality risk factors were identified using a multivariable regression analysis including all characteristics that were significantly different between NMS cases resulting vs. not resulting in death. RESULTS 683 cases with NMS were analyzed (median age = 36 years, males = 62.1%). In a multivariable model, independent predictors of NMS mortality were lack of antipsychotic discontinuation (odds ratio (OR) = 4.39 95% confidence interval (CI) = 2.14-8.99; p < 0.0001), respiratory problems (OR = 3.54 95%CI = 1.71-7.32; p = 0.0004), severity of hyperthermia (Unit-OR = 1.30, 95%CI = 1.16-1.46; p < 0.0001), and older age (Unit-OR = 1.05, 95%CI = 1.02-1.07; p = 0.0014). Even in univariate, patient-level analyses, antipsychotic formulation was not related to death (oral antipsychotic (OAP): n = 39/554 (7.0%) vs. long-acting injectable (LAI): n = 13/129 (10.1%); p = 0.2413). Similarly, death with NMS was not related to antipsychotic class (first-generation antipsychotic: n = 38/433 (8.8%) vs. second-generation antipsychotic: n = 8/180 (4.4%); p = 0.0638). Non-antipsychotic co-treatments were not associated with NMS mortality. CONCLUSION Despite reliance on case reports, these findings indicate that presence of respiratory alterations, severity of hyperthermia, and older age should alert clinicians to a higher NMS mortality risk, and that antipsychotics should be stopped to reduce mortality, yet when NMS arises on LAIs, mortality is not increased vs. OAPs.
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Affiliation(s)
- Daniel Guinart
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Institut de Neuropsiquiatria i Addiccions (INAD), Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Departament de Psiquiatria, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Jose M Rubio
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Justin Pereira
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA
| | - Renato de Filippis
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Chiara Gastaldon
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - John M Kane
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.,Department of Child and Adolescent Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Fervienza A, López-Baamonde M, Jacas A, Muñoz G, Ibáñez C, Del Rio ME. Neuroleptic malignant syndrome in a postoperative patient: a case report. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00107-9. [PMID: 34535293 DOI: 10.1016/j.redar.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/28/2022]
Abstract
Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis. A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity. Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms. The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.
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Affiliation(s)
- A Fervienza
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, España.
| | | | - A Jacas
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, España
| | - G Muñoz
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, España
| | - C Ibáñez
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, España
| | - M E Del Rio
- Anestesiología, Hospital Clinic de Barcelona, Barcelona, España
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Abstract
Introduction: Many drugs are known to induce malignant syndromes. The most common malignant syndromes are induced by the use of antipsychotics and anesthetics and the withdrawal of anti-Parkinson drugs. As the clinical manifestations of antipsychotic malignant syndrome, Parkinson's disease hyperpyrexia syndrome and anesthetic-induced malignant syndrome are very similar, they are easily confused in the clinic.Areas covered: We reviewed articles published between 1960 and April 2021 describing malignant syndromes. This paper provides a detailed literature review of malignant syndromes and important guidance for the diagnosis and treatment of malignant syndromes to clinicians.Expert opinion: Although malignant syndromes are rare conditions with a low incidence, these conditions usually progress rapidly and can endanger patients' lives, meriting attention from clinicians. The typical clinical manifestations of malignant syndromes are hyperpyrexia, muscular rigidity, an altered mental status and increased levels of creatine kinase; however, the pathophysiology, treatment and prognosis of different malignant syndromes are quite different. Prompt diagnosis and treatment may significantly improve the prognosis of patients with malignant syndromes.
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Affiliation(s)
- Minghua Tao
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Jiyuan Li
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Xuefeng Wang
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xin Tian
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Bell JD, Hall C, Sandall J. Ziprasidone Associated Neuroleptic Malignant Syndrome. Kans J Med 2021; 14:82-83. [PMID: 33763185 PMCID: PMC7984742 DOI: 10.17161/kjm.vol1411970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/21/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Chancen Hall
- Department of Anesthesiology, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Justin Sandall
- Department of Anesthesiology, University of Kansas School of Medicine-Wichita, Wichita, KS
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Valdes B, Salani D, King B, De Oliveira GC. Recognition and Treatment of Psychiatric Emergencies for Health Care Providers in the Emergency Department: Panic Attack, Panic Disorder, and Adverse Drug Reactions. J Emerg Nurs 2021; 47:459-468. [PMID: 33714565 DOI: 10.1016/j.jen.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 01/04/2021] [Accepted: 01/12/2021] [Indexed: 10/21/2022]
Abstract
Mental health disorders are common in the United States and may cause significant disturbances in all aspects of a person's life. Individuals with mental health disorders often present to emergency departments for health care. Recognizing and managing common psychiatric emergencies may be challenging for non-mental health providers. The Diagnostic Statistical Manual-5 diagnostic criteria will be discussed and reviewed for panic attack and panic disorder. Both pharmacologic and nonpharmacologic treatment strategies will also be addressed. Adverse drug reactions associated with antipsychotics and selective serotonin reuptake inhibitors are another common psychiatric emergency that will be examined, offering potential management strategies. The objective of this clinical manuscript is to educate emergency health care providers about specific psychiatric emergencies, including panic attack, panic disorder, and adverse drug reactions associated with mental health treatment medications.
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Oneib B, Zaimi O. Neuroleptic malignant syndrome: clinical expression, complication, course, and atypical clinical picture. MIDDLE EAST CURRENT PSYCHIATRY 2021. [DOI: 10.1186/s43045-020-00081-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Neuroleptic malignant syndrome (NMS) is an uncommon and lethal side effect of neuroleptics. The clinical expression of this syndrome is diverse. Even with criteria diagnosis, it is hard to recognize it easily.
We report a series of 25 cases of NMS among patients hospitalized in psychiatric service at Oujda for 5 years. We have described the clinical characteristics of NMS in these patients, the treatments received, the management, and the course of this syndrome.
Results
Most of the patients are hospitalized for psychotic or affective disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM V) criteria. 92% of patients received conventional neuroleptic, and half of them were under the injectable form. No patient took long-acting injectable antipsychotics. 36% of patients received neuroleptics for the first time. NMS appeared in the first week after the admission in psychiatric service among 24 patients. The most common clinical and biological signs were muscular rigidity, the elevation of creatine phosphokinase (CPK), and alteration of blood pressure. Other symptoms were found in proportion varied between 24% and 72%. 32% of the patients did not develop complications. One patient developed renal failure. All patients recovered, and no deaths were recorded.
Conclusions
Early recognition of NMS help to rescue patient. It is necessary to detect this syndrome even in the absence of main signs such as fever.
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Wadoo O, Ouanes S, Firdosi M. Neuroleptic malignant syndrome: a guide for psychiatrists. BJPSYCH ADVANCES 2020. [DOI: 10.1192/bja.2020.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYNeuroleptic 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.
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Kuhlwilm L, Schönfeldt-Lecuona C, Gahr M, Connemann BJ, Keller F, Sartorius A. The neuroleptic malignant syndrome-a systematic case series analysis focusing on therapy regimes and outcome. Acta Psychiatr Scand 2020; 142:233-241. [PMID: 32659853 DOI: 10.1111/acps.13215] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening antipsychotic-associated disorder that requires an efficient and timely therapy. The aim of the study was to compare the effectiveness of different NMS therapies and to analyze its outcome depending on NMS severity. METHOD Systematic search for NMS cases in biomedical databases. The focus of the analysis was on therapy with dantrolene, bromocriptine, and electroconvulsive therapy (ECT) when each was compared with symptomatic therapy. Primary outcomes were the survival rate and the duration of treatment. RESULT 405 case reports were included. Overall, no statistically significant differences regarding mortality rate or duration of treatment were found between dantrolene, bromocriptine, or ECT compared to supportive care. A subgroup analysis regarding NMS severity showed that the mortality under specific NMS pharmacotherapy (dantrolene, bromocriptine) and under ECT was significantly lower than under purely symptomatic therapy in severe NMS (P = 0.018). The difference was not significant in mild and moderate cases. DISCUSSION An overall superiority of the specific NMS therapy (dantrolene, bromocriptine, and ECT) was not found in this study. When regarding severity classification, specific therapies were superior but only in severe cases, and ECT showed the lowest mortality rate. In previous case series, an effect on survival or the duration of the disease could only be observed in part for specific therapies, but the evidence available is inconsistent. The results of this study support our hypothesis that NMS treatment with dantrolene, bromocriptine, and ECT is advantageous over purely symptomatic therapy in severe NMS cases.
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Affiliation(s)
- L Kuhlwilm
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - C Schönfeldt-Lecuona
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - M Gahr
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - B J Connemann
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - F Keller
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
| | - A Sartorius
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal syndrome classically encountered in patients receiving typical antipsychotic agents. However, many physicians have also reported the occurrence of NMS with atypical antipsychotics, notably with atypical presentations. In this report, we present a case in which a patient's antipsychotic regimen during a psychotic episode (which involved both typical and atypical antipsychotics) subsequently led to NMS. During his stay, the patient developed an altered level of consciousness, elevation of creatine phosphokinase, hemodynamic instability, and a fever. However, the patient did not have signs of rigidity, the cardinal sign of this syndrome. The authors concluded that patients could develop NMS without rigidity while receiving an antipsychotic. Given this presentation, the authors suggest that clinicians have a high level of suspicion for NMS to avoid misdiagnosis and subsequent adverse consequences. Hence, clinicians must be vigilant about atypical presentations of NMS without rigidity.
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Morcos M, Corns J, Hillen JB. Pharmacist-Initiated Management of a Suspected Case of Risperidone-Induced Neuroleptic Malignant Syndrome in an Aged-Care Resident. The Role of Residential Medication Management Reviews in Medication Safety. J Pharm Pract 2020; 33:382-385. [DOI: 10.1177/0897190018806414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 70-year-old female aged-care resident was referred by her general practitioner for a residential medication management review after nurses reported difficulties with swallowing, episodes of hyperthermia, elevated blood pressure, and tachycardia. These symptoms were accompanied by increasing confusion and drowsiness. Risperidone had recently been prescribed to treat behavioral and psychological symptoms of dementia. This case study describes the pharmacist-initiated management of the symptoms through a national medication review program. It demonstrates the valuable role collaborative medication reviews play in managing adverse drug reactions in aged-care.
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Sato I, Onishi H, Kawanishi C, Yamada S, Ishida M, Kawakami K. Neuroleptic malignant syndrome in patients with cancer: a systematic review. BMJ Support Palliat Care 2020; 10:265-270. [PMID: 32414787 DOI: 10.1136/bmjspcare-2020-002200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/07/2020] [Accepted: 04/20/2020] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,The Keihanshin Consortium for Fostering the Next Generation of Global Leaders in Research (K-CONNEX), Kyoto, Japan
| | - Hideki Onishi
- Department of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Chiaki Kawanishi
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Shuhei Yamada
- Department of Quality and Patient Safety Management, Chiba Cancer Center, Chiba, Japan
| | - Mayumi Ishida
- Department of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Abstract
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.
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Affiliation(s)
- Lisa A Ruth-Sahd
- Lisa A. Ruth-Sahd is a professor at the York College of Pennsylvania in York, Pa., and Georgetown University in Washington, D.C. Darris Rodrigues is a nurse at St. Luke's University Health Network in Fountain Hill, Pa. Elizabeth Shreve is a nursing student at York College of Pennsylvania
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León-Amenero D, Huarcaya-Victoria J. Neuroleptic Malignant Syndrome in Children and Adolescents: Systematic Review of Case Reports. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 50:S0034-7450(19)30075-7. [PMID: 33735054 DOI: 10.1016/j.rcp.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal drug adverse reaction. There are still few studies of this entity in the child-adolescent population. OBJECTIVES Describe the clinical, laboratory and therapeutic characteristics of children and adolescent patients with NMS. Analyse the grouping of symptoms present in NMS in the same population. MATERIAL AND METHODS A MEDLINE/PubMed search of all reported cases of NMS from January 2000 to November 2018 was performed and demographic, clinical, laboratory and therapeutic variables were identified. A factorial analysis of the symptoms was performed. RESULTS 57 patients (42 males and 15 females) were included, (mean age 13.65±3.89 years). The onset of NMS occurred at 11.25±20.27 days with typical antipsychotics and at 13.69±22.43 days with atypical antipsychotics. The most common symptoms were muscle stiffness (84.2%), autonomic instability (84.2%) and fever (78.9). The most common laboratory findings were CPK elevation and leucocytosis (42.1%). The most used treatment was benzodiazepines (28.1%). In the exploratory factorial analysis of the symptoms we found 3factors: 1) "Catatonic" with mutism (0.912), negativism (0.825) and waxy flexibility (0.522); 2) "Extrapyramidal" with altered gait (0.860), involuntary abnormal movements (0.605), muscle stiffness (0.534) and sialorrhoea (0.430); and 3) "Autonomic instability" with fever (0.798), impaired consciousness (0.795) and autonomic instability (0.387). CONCLUSIONS NMS in children and adolescents could be of 3types: catatonic, extrapyramidal and autonomic unstable.
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Affiliation(s)
- Deborah León-Amenero
- Médico psiquiatría de niños y adolescentes, Servicio de Psiquiatría Infanto-juvenil, Departamento de Psiquiatría, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Jeff Huarcaya-Victoria
- Universidad de San Martín de Porres, Facultad de Medicina, Centro de Investigación en Salud Pública, Lima, Perú; Médico psiquiatra, Servicio de Psiquiatría General, Departamento de Psiquiatría, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú.
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Esang M, Goldstein S, Dhami R. 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. Cureus 2019; 11:e4840. [PMID: 31410323 PMCID: PMC6684120 DOI: 10.7759/cureus.4840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Michael Esang
- Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, USA
| | - Sabina Goldstein
- Miscellaneous, American University of the Caribbean, Cupecoy, SXM
| | - Ravina Dhami
- Miscellaneous, American University of the Caribbean, Cupecoy, SXM
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Vellekkatt F, Kuppili PP, Bharadwaj B, Menon V. Atypical neuroleptic malignant syndrome - A case report. Asian J Psychiatr 2019; 43:7-8. [PMID: 31071486 DOI: 10.1016/j.ajp.2019.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/31/2019] [Accepted: 04/22/2019] [Indexed: 11/17/2022]
Abstract
Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse effect of antipsychotics. Atypical presentation of NMS with drugs which are not potential D2 blockers raises question for an alternative hypothesis for NMS. A 30 year old male presented with irritability, assaultive behavior, persecutory delusion and auditory hallucination for three days. Past history of 3 similar episodes. 1st episode preceded by fever and associated with cerebral edema. Subsequent episodes not preceded by fever and patient was treated with Risperidone and Olanzapine. After admission patient was started on Risperidone along with THP when he had fever, tremors, altered sensorium and rigidity at 3 mg dose. After stopping Risperidone fever and rigidity improved with worsening of psychotic symptoms. Following this Olanzapine was started and very gradually uptitrated to 7.5 mg when patient had recurrence of fever and disorientation without tremors and minimal rigidity. Both the instances blood investigations including CPK levels were normal except for thrombocytopenia and leucopenia. Provisional impression of NMS was made in both instances. After stopping Olanzapine fever subsided with improvement of blood counts. Following this patient had catatonic symptoms for which patient received 9 sessions of Electroconvulsive therapy (ECT). In atypical presentations of NMS, hyperthermia and muscle rigidity may be absent, posing diagnostic dilemma. So there is a need for broadening the diagnostic criteria and NMS must be considered with a high index of suspicion.
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Affiliation(s)
- Favaz Vellekkatt
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India.
| | - Pooja Patnaik Kuppili
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Balaji Bharadwaj
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
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Manabe S, Yanagi H, Ozawa H, Takagi A. Neuroleptic malignant syndrome as part of an akinetic crisis associated with sepsis in a patient with Lewy body disease. BMJ Case Rep 2019; 12:12/2/bcr-2018-227216. [PMID: 30824461 DOI: 10.1136/bcr-2018-227216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 65-year-old Japanese woman with Parkinson's disease, later diagnosed with Lewy body disease, presented with a 2-day history of systemic tremors. She also had fever without rigidity or creatine kinase (CK) elevation. She was diagnosed with sepsis caused by pyelonephritis with acute kidney injury and parkinsonism exacerbation. Although antibiotic and fluid therapy improved her pyuria and renal function, her fever and tremors persisted. On the fourth day, her symptoms worsened and resulted in cardiopulmonary arrest; however, quick resuscitation allowed the return of spontaneous circulation. Simultaneously, hyperthermia, altered consciousness, extrapyramidal symptoms, dysautonomia and CK elevation were noted. Thus, dantrolene administration was initiated with a tentative diagnosis of neuroleptic malignant syndrome (NMS). This caused her fever to subside, and her symptoms gradually improved. It was difficult to distinguish between parkinsonism exacerbation associated with sepsis and NMS. Physicians should consider NMS early on, even if the patient does not fulfil the diagnostic criteria.
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Affiliation(s)
- Saki Manabe
- Division of General Internal Medicine, School of Medicine, Tokai University, Isehara, Japan
| | - Hidetaka Yanagi
- Division of General Internal Medicine, School of Medicine, Tokai University, Isehara, Japan
| | - Hideki Ozawa
- Division of General Internal Medicine, School of Medicine, Tokai University, Isehara, Japan
| | - Atsushi Takagi
- Division of General Internal Medicine, School of Medicine, Tokai University, Isehara, Japan
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Ngo V, Guerrero A, Lanum D, Burgett-Moreno M, Fenati G, Barr S, Neeki MM. Emergent Treatment of Neuroleptic Malignant Syndrome Induced by Antipsychotic Monotherapy Using Dantrolene. Clin Pract Cases Emerg Med 2019; 3:16-23. [PMID: 30775657 PMCID: PMC6366389 DOI: 10.5811/cpcem.2018.11.39667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/11/2018] [Accepted: 11/07/2018] [Indexed: 11/30/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication resulting from neuroleptic drug therapy. Presentation of NMS can vary, and diagnosis relies primarily upon medical history and symptomatology. Due to the potential delay in diagnosis, emergency physicians should remain vigilant in recognizing the symptoms of NMS and be prepared to initiate immediate treatment following diagnosis. Dantrolene, which has been used for spasticity and malignant hyperthermia, has been reported as a potential treatment for NMS and led to off-label use for NMS. We report two cases of NMS induced by antipsychotic monotherapy for which dantrolene was administered.
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Affiliation(s)
- Vivian Ngo
- Arrowhead Regional Medical Center, Department of Family Medicine, Colton, California
| | - Alfredo Guerrero
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - David Lanum
- Arrowhead Regional Medical Center, Department of Family Medicine, Colton, California.,California University of Sciences and Medicine, Department of Emergency Medicine, Colton, California
| | | | - Gregory Fenati
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Department of Emergency Medicine, Colton, California
| | - Steven Barr
- Arrowhead Regional Medical Center, Department of Anesthesia, Colton, California
| | - Michael M Neeki
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.,California University of Sciences and Medicine, Department of Emergency Medicine, Colton, California
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Characteristics of Patients Experiencing Extrapyramidal Symptoms or Other Movement Disorders Related to Dopamine Receptor Blocking Agent Therapy. J Clin Psychopharmacol 2019; 39:336-343. [PMID: 31205194 PMCID: PMC6594730 DOI: 10.1097/jcp.0000000000001061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE/BACKGROUND Dopamine receptor blocking agents (DRBAs), also known as antipsychotics, are medications widely used to treat a growing number of mental health diagnoses. However, their utility is limited by the potential to cause serious adverse movement reactions. Akathisia, dystonia, parkinsonism, and tardive dyskinesia (collectively known as extrapyramidal symptoms or EPSs) are associated with reduced social and occupational functioning, negative patient attitudes toward treatment, and nonadherence to pharmacotherapy. Neuroleptic malignant syndrome is a life-threatening reaction that can result from DRBA use and cause musculoskeletal dysfunction. The aim of this study is to profile patients who have developed DRBA-related movement adverse effects and identify risk factors significantly associated with each subtype of EPSs or other movement disorders (OMDs) such as neuroleptic malignant syndrome. METHODS/PROCEDURES A report of all potential DRBA-related EPSs or OMDs occurrences within a large community hospital network was generated using International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) billing codes. Each patient encounter was manually reviewed to confirm that a documented case of DRBA-related EPSs or OMDs had indeed occurred and subsequently determine the likely causative agent(s). FINDINGS/RESULTS The resultant cohort of 148 patients experiencing unique DRBA-related EPS or OMD events was analyzed. The average patient was female, middle-aged, and overweight. The most common DRBAs precipitating EPSs or OMDs were haloperidol and quetiapine. In the population studied, age was significantly associated with the subtype of EPSs experienced such that those patients with akathisia and dystonia tended to be younger, whereas those with tardive dyskinesia tended to be older. Body mass index (BMI) category was also negatively correlated with the incidence of dystonia. In addition, it was observed that exposure to specific DRBAs, classes, and routes of administration significantly affected the risk of developing different subtypes of EPSs or OMDs in the study population. IMPLICATIONS/CONCLUSIONS To our knowledge, this is the first study to describe an association between age and BMI with the risk of akathisia and dystonia, respectively, in patients taking DRBAs. Other trends observed with age and BMI in patients developing DRBA-related EPSs support previously reported findings. Expanding the knowledge base of individual characteristics associated with the risk of developing different subtypes of EPSs or OMDs can help providers and patients anticipate and attempt to mitigate these reactions, and may ultimately improve adherence to DRBA therapy.
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41
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Almegren M. Pulmonary embolism in a patient with neuroleptic malignant syndrome. Hematol Rep 2018; 10:7753. [PMID: 30631408 PMCID: PMC6297863 DOI: 10.4081/hr.2018.7753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/16/2018] [Indexed: 11/24/2022] Open
Abstract
Venous thromboembolism is one of the complications in patients prescribed antipsychotic medications. Neuroleptic malignant syndrome (NMS) is a rare side effect of antipsychotic medications in this population. In this case, a young patient, who presented with NMS after a recent start of antipsychotic medications, had developed a pulmonary embolism despite standard of care measures of venous thromboprophylaxis and early mobilization. A low threshold of VTE suspicion and effective preventive measures are both required in order to avoid this preventable complication in this population.
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Affiliation(s)
- Mosaad Almegren
- Department of Medicine, Al Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
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42
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Chime C, Alemam A, Kumar K, Dhallu M. Acute Abdomen with Ileus: A Heralding Presentation of Neuroleptic Malignant Syndrome. Case Rep Gastroenterol 2018; 12:566-569. [PMID: 30323731 PMCID: PMC6180277 DOI: 10.1159/000492460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/20/2018] [Indexed: 11/24/2022] Open
Abstract
The pathophysiology of neuroleptic malignant syndrome (NMS) with use of psychotropic drugs is still unclear. Although a rare event with an incidence of 0.02–3.2%, when not promptly recognized and managed, it carries a high mortality (10–20%) and morbidity rate. Presentation can be either typical, with muscle rigidity and hyperpyrexia, or atypical, the latter posing diagnostic and early management challenges in clinical practice. Our patient presented with delayed fever and ileus, making early diagnosis difficult. We propose that NMS be considered an alternate diagnosis in patients using psychotropic medications and manifest ileus and delayed fever, especially after other differentials have been excluded.
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Affiliation(s)
- Chukwunonso Chime
- Bronx Care Health System - Affiliate of Mount Sinai Hospital System, Bronx, New York, USA
| | - Ahmed Alemam
- Bronx Care Health System - Affiliate of Mount Sinai Hospital System, Bronx, New York, USA
| | - Kishore Kumar
- Bronx Care Health System - Affiliate of Mount Sinai Hospital System, Bronx, New York, USA
| | - Manjeet Dhallu
- Bronx Care Health System - Affiliate of Mount Sinai Hospital System, Bronx, New York, USA
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Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare but severe undesired complication of psychopharmacological treatment. The mortality has shown a significant decrease since its first description. Knowledge of NMS is important for every clinician because of the need for rapid diagnosis and treatment. OBJECTIVE This article presents a review and critical appraisal of the current study situation for NMS. Recommendations for diagnostics, differential diagnostics and treatment are presented particularly from a clinical perspective. MATERIAL AND METHODS A literature review with the keywords "neuroleptic malignant syndrome", "Malignes neuroleptisches Syndrom" and various psychotropic drugs was performed in PubMed. The database of the Working Group for Pharmaceutical Treatment of Psychiatric Diseases (Arbeitsgemeinschaft für Arzneimitteltherapie bei psychiatrischen Erkrankungen, AGATE) was analyzed with respect to registered cases of the undesired side effect NMS. RESULTS In contrast to the first description, which also led to the name, there are now case reports of clinical conditions similar to NMS, which were obviously triggered by several groups of psychotropic drugs not just antipsychotic agents (German: Neuroleptika). Treatment recommendations exist whereby the effectiveness cannot always be scientifically substantiated; however, it is still undisputed that a rapid initiation of treatment is of great importance. DISCUSSION The psychiatrist must be familiar with the symptoms of NMS, its differential diagnosis and the therapeutic options for a rapid and effective treatment. Further studies are urgently needed for scientific substantiation of the pathophysiology of NMS and to develop evidence-based guidelines for treatment.
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Affiliation(s)
- R Knorr
- Klinik für Psychiatrie und Psychotherapie, Zentrum für Psychiatrie Reichenau, Feursteinstraße 55, 78479, Reichenau, Deutschland.
- Institut AGATE gGmbH, Pentling, Deutschland.
| | - J Schöllkopf
- Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
| | - E Haen
- Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
- Klinische Pharmakologie am Lehrstuhl für Psychiatrie, Universität Regensburg, Regensburg, Deutschland
- Institut AGATE gGmbH, Pentling, Deutschland
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Whyte CJ, Rosini JM. Dantrolene for Treatment of Suspected Neuroleptic Malignant Syndrome. J Emerg Nurs 2018; 44:207-209. [DOI: 10.1016/j.jen.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Sarkar S, Gupta N. Drug information update. Atypical antipsychotics and neuroleptic malignant syndrome: nuances and pragmatics of the association. BJPsych Bull 2017; 41:211-216. [PMID: 28811916 PMCID: PMC5537576 DOI: 10.1192/pb.bp.116.053736] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal adverse event associated with the use of antipsychotics. Although atypical antipsychotics were initially considered to carry no risk of NMS, reports have accumulated over time implicating them in NMS causation. Almost all atypical antipsychotics have been reported to be associated with NMS. The clinical profile of NMS caused by certain atypical antipsychotics such as clozapine has been reported to be considerably different from the NMS produced by typical antipsychotics, with diaphoresis encountered more commonly, and rigidity and tremor encountered less frequently. This article briefly discusses the evidence relating to the occurrence, presentation and management of NMS induced by atypical antipsychotics.
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Affiliation(s)
| | - Nitin Gupta
- Government Medical College and Hospital, Chandigarh, India
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46
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Reilly TJ, Cross S, Taylor DM, Haslam R, Tomlin SC, Gaastra B. Neuroleptic malignant syndrome following catatonia: Vigilance is the price of antipsychotic prescription. SAGE Open Med Case Rep 2017; 5:2050313X17695999. [PMID: 28491312 PMCID: PMC5406192 DOI: 10.1177/2050313x17695999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/23/2017] [Indexed: 11/15/2022] Open
Abstract
Objectives: To describe a case of neuroleptic malignant syndrome following antipsychotic treatment of catatonia, highlighting the potentially serious complications of this rare adverse drug reaction. Methods: We present a case report of a patient who developed this syndrome with various sequelae. Results: The patient developed neuroleptic after being treated with lorazepam and olanzapine for catatonia. He subsequently developed the complications of rhabdomyolysis, acute kidney injury, pulmonary embolism, urinary retention and ileus. He received high-dose lorazepam, anticoagulation and intravenous fluids. Antipsychotic medication in the form of haloperidol was reinstated with no adverse effect, and he went on to make a full recovery. Conclusions: This case illustrates the potential life-threatening complications of neuroleptic malignant syndrome and the need for a low index of clinical suspicion. It also highlights the lack of evidence for treatment of catatonia, including the use of antipsychotics.
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Affiliation(s)
- Thomas J Reilly
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Ladywell Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sean Cross
- Department of Psychological Medicine, King's College Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - David M Taylor
- Pharmaceutical Sciences Clinical Academic Group, King's Health Partners, South London and Maudsley NHS Foundation Trust, London, UK
| | - Richard Haslam
- Ladywell Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sophie C Tomlin
- Ladywell Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Benjamin Gaastra
- Department of Psychological Medicine, King's College Hospital, South London and Maudsley NHS Foundation Trust, London, UK
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47
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Oruch R, Pryme IF, Engelsen BA, Lund A. Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatr Dis Treat 2017; 13:161-175. [PMID: 28144147 PMCID: PMC5248946 DOI: 10.2147/ndt.s118438] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ramadhan Oruch
- Department of Pharmacology and Toxicology, School of Pharmacy, Benghazi University, Benghazi, Libya
| | | | | | - Anders Lund
- Department of Clinical Medicine, Section of Psychiatry, University of Bergen, Bergen, Norway
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48
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Parkinsonismo severo con insuficiencia respiratoria en paciente de diálisis peritoneal. Nefrologia 2016; 36:721-722. [DOI: 10.1016/j.nefro.2016.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/05/2016] [Indexed: 11/21/2022] Open
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Gomes RQD, Dos Santos-Júnior A, Dias GADAS, Cais CFDS. Diagnosis and implications in the therapeutic management of patient with afebrile neurolepctic malignant syndrome. Oxf Med Case Reports 2016; 2016:omw067. [PMID: 27606070 PMCID: PMC5012583 DOI: 10.1093/omcr/omw067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/22/2016] [Accepted: 06/25/2016] [Indexed: 11/18/2022] Open
Abstract
This report aims at raising clinical awareness for the diagnosis of atypical presentations of neuroleptic malignant syndrome (NMS). We describe the case of a female patient with NMS symptoms, except fever, after starting the use of chlorpromazine. The afebrile condition delayed the consideration of NMS by the emergency clinicians who provided her initial assessment. Before this consideration, an anticholinergic agent, not recommended at this condition, was inadvertently prescribed. This might have contributed to the worsening of symptoms. NMS is a life-threatening idiosyncratic reaction most often seen as complication of antipsychotic treatment. Its clinical spectrum is broad and its diagnosis should be considered even if the patients do not fulfill all the possible described symptoms.
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Affiliation(s)
- Rafael Quintes Ducasble Gomes
- Department of Psychiatry, Faculty of Medical Sciences, University of Campinas (Unicamp) , Rua Tessália Vieira de Camargo , 126, Campinas 13083-894, Brazil
| | - Amilton Dos Santos-Júnior
- Department of Psychiatry, Faculty of Medical Sciences, University of Campinas (Unicamp) , Rua Tessália Vieira de Camargo , 126, Campinas 13083-894, Brazil
| | - Gabriel Augusto de Araujo Silva Dias
- Department of Psychiatry, Faculty of Medical Sciences, University of Campinas (Unicamp) , Rua Tessália Vieira de Camargo , 126, Campinas 13083-894, Brazil
| | - Carlos Filinto da Silva Cais
- Department of Psychiatry, Faculty of Medical Sciences, University of Campinas (Unicamp) , Rua Tessália Vieira de Camargo , 126, Campinas 13083-894, Brazil
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50
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Abstract
The development of drugs to treat psychosis is a fascinating nexus for understanding mechanisms underlying disorders of mind and movement. Although the risk of drug-induced extrapyramidal syndromes has been mitigated by the acceptance of less potent dopamine antagonists, expansive marketing and off-label use has increased the number of susceptible people who may be at risk for these neurologic effects. Clinicians need to be familiar with advances in diagnosis and management, which are reviewed herein. A better understanding of drug-induced effects on the motor circuit may improve patient safety, enhance antipsychotic effectiveness, and provide insights into mechanisms underlying antipsychotic activity in parallel brain circuits.
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Affiliation(s)
- Stanley N Caroff
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 300 Blockley Hall, Philadelphia, PA 19104, USA.
| | - E Cabrina Campbell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Corporal Michael J. Crescenz Veterans Affairs Medical Center-116A, University & Woodland Avenues, Philadelphia, PA 19104, USA
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