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Kraaijvanger N, Mieloo T. Neuroleptic malignant syndrome after overdose of haloperidol - A case report. Toxicol Rep 2024; 12:356-360. [PMID: 38560509 PMCID: PMC10981033 DOI: 10.1016/j.toxrep.2024.03.003] [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] [Received: 01/13/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction The Neuroleptic Malignant Syndrome (NMS), alternatively referred to as the Antipsychotic Malignant Syndrome, is a potentially fatal condition that is infrequently observed and is linked to the administration of antipsychotic medications. This syndrome is characterized by a disturbance in consciousness, autonomic instability manifesting as hyperthermia, and muscular rigidity. The onset of this syndrome is typically within the initial month of treatment or following an escalation in the dosage of an antipsychotic medication. This case report delineates a case where NMS was precipitated by an excessive intake of haloperidol, a typical antipsychotic drug. Case description In the Emergency Department (ED), a 23-year-old male was admitted following an overdose of haloperidol, a typical antipsychotic drug. The patient exhibited symptoms of tachypnea and tachycardia, and initially presented with hypotension. His level of consciousness was variable, but maximal upon stimulation. Notably, there was a significant increase in muscle tension, characterized by cogwheel rigidity. His body temperature rose to 38.6 degrees Celsius. Laboratory findings revealed a substantial high anion gap metabolic acidosis, with a lactate level of 21.2 mmol/L. Additionally, his creatine kinase level was elevated, measuring 1347 U/L. The therapeutic approach encompassed the intravenous administration of midazolam (2.5 mg), lorazepam (2.5 mg), and biperiden (5 mg), in conjunction with resuscitation involving 2 liters of 0.9% NaCl. The patient demonstrated a positive response to this regimen, leading to his admission to the ward. Following a full recovery, he was discharged from the hospital the subsequent day. Discussion The patient in our case fulfilled all the diagnostic criteria for NMS as stipulated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). NMS is not contingent on the dosage, although an increased dosage does elevate the risk. A thorough review of existing literature did not yield any cases mirroring ours. Conclusion In conclusion, we present a case where NMS developed after an overdose of haloperidol.
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Affiliation(s)
- Nicole Kraaijvanger
- Emergency Department, Leiden University Medical Center, Leiden, the Netherlands
| | - Tim Mieloo
- Emergency Department, Leiden University Medical Center, Leiden, the Netherlands
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Ramirez-Bermudez J, Restrepo-Martinez M, Espinola-Nadurille M, Martinez-Angeles V, Lopez-Hernandez JC, Hernandez-Vanegas LE, Martinez-Carrillo F, Ruiz-Garcia R, Rivas-Alonso V, Flores-Rivera J, Pollak TA. Examining the Features of Neuroleptic Malignant Syndrome in Anti-NMDA Receptor Encephalitis: A Case-Control Study. J Acad Consult Liaison Psychiatry 2024; 65:222-230. [PMID: 38151160 DOI: 10.1016/j.jaclp.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor encephalitis (ANMDARE) is a neuroimmunological disorder that frequently improves with immunotherapy. Symptomatic treatment with antipsychotics is common in the early stages when psychiatric symptoms predominate, and their use has been associated with serious side effects including neuroleptic malignant syndrome (NMS). The observation of an adverse response to antipsychotics, raising the suspicion of NMS, has been included as a criterion for possible autoimmune psychosis. METHODS This case-control study included patients who received antipsychotics before referral to the National Institute of Neurology and Neurosurgery of Mexico, where they were diagnosed as having definite ANMDARE, and patients with ANMDARE who did not receive antipsychotics before referral. The neurologic and systemic features that are used to measure an adverse response to antipsychotics, raising the suspicion of NMS, were measured in both groups, including akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, and hyperthermia. A logistic regression analysis was used to determine the relationship between the previous use of antipsychotics and the occurrence of NMS-like reactions. RESULTS A total sample of 112 patients with definite ANMDARE were included in the study. Fifty patients received antipsychotics before being referred to our institution. In this group, thirty-six patients (72%) were initially classified as having an adverse response, raising the suspicion of NMS, with the following features: akinesia (64%), autonomic instability (58%), generalized rigidity (52%), elevated concentrations of creatine phosphokinase (50%), and hyperthermia (14%). Six patients fulfilled the criteria for NMS (12%). The comparison with patients who did not receive antipsychotics before the clinical assessment did not show a significant difference between groups regarding the frequency of akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, or hyperthermia. Among different antipsychotics, only haloperidol was significantly associated with generalized rigidity as compared to patients who did not receive antipsychotics. CONCLUSIONS Our study supports previous observations about the high frequency of autonomic dysfunction, hyperthermia, tachycardia, rigidity, and elevated creatine phosphokinase levels in patients with anti-NMDAR encephalitis following the administration of antipsychotic medications. Nevertheless, our study does not suggest a causal link between atypical antipsychotics and the onset of these neurological symptoms, as they were equally frequent among the group of patients who did not receive antipsychotic treatment.
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Affiliation(s)
- Jesus Ramirez-Bermudez
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico.
| | - Miguel Restrepo-Martinez
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Mariana Espinola-Nadurille
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Victoria Martinez-Angeles
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Juan Carlos Lopez-Hernandez
- Department of Neurological Emergencies, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Laura E Hernandez-Vanegas
- Department of Clinical Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Francisco Martinez-Carrillo
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Ramiro Ruiz-Garcia
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Veronica Rivas-Alonso
- Department of Clinical Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Jose Flores-Rivera
- Department of Clinical Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London
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Omote D, Kuramoto N. A Case of Rhabdomyolysis Induced by Antipsychotic Medication With Creatine Kinase (CK) Levels Elevated to 420,000 U/L, Resulting in Acute Kidney Injury (AKI) and Necessitating Hemodialysis. Cureus 2024; 16:e58145. [PMID: 38741842 PMCID: PMC11088958 DOI: 10.7759/cureus.58145] [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: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
A 45-year-old man on public welfare, who had been visiting a psychiatric hospital for schizoaffective disorder, began working as a package delivery person for the first time in the morning after receiving welfare. In the afternoon, he noticed pain in his lower back. By evening, he was unable to move, prompting an emergency call and transportation to our hospital. Blood tests revealed renal damage and elevated creatine kinase (CK) levels, resulting in hospitalization. Although he received fluid replacement after admission, he did not urinate, and his CK levels increased to 420,000 U/L, necessitating hemodialysis. Subsequently, his CK levels gradually improved over time, accompanied by increased urine output. Approximately three weeks after initiating hemodialysis, he was weaned off the treatment and discharged home 40 days after admission.
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Affiliation(s)
- Daichi Omote
- Nephrology, Narita Red Cross Hospital, Narita-shi, JPN
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Macedo E, Rodrigues F, Marques AR, Ribeiro L, Silveira P. Neuroleptic Malignant Syndrome: An Intensive Care Unit Case of Exceptionally High Creatinine Kinase and Myoglobin Levels. Cureus 2024; 16:e56306. [PMID: 38628997 PMCID: PMC11019339 DOI: 10.7759/cureus.56306] [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: 03/16/2024] [Indexed: 04/19/2024] Open
Abstract
Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening neurologic emergency known to be related to the administration or sudden withdrawal of dopaminergic medications. The clinical course, symptoms, and bloodwork are very heterogeneous, making this syndrome difficult to identify. Thus, NMS is a diagnosis of exclusion. We present a case of severe NMS with exceptionally high creatinine kinase (CK) and myoglobin levels with unclear etiology and a challenging differential diagnosis. Also, our case stands out because it was serious, unique, and had a favorable outcome, which could contribute to the management of future similar cases.
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Affiliation(s)
| | | | | | - Luís Ribeiro
- Critical Care Medicine, Hospital de Braga, Braga, PRT
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Fader JP, Walker Evans M, Lundgren AM, Sigmund TB, Allen TJ. Haloperidol-Induced Neuroleptic Malignant Syndrome: A Case Report. Cureus 2024; 16:e57276. [PMID: 38686249 PMCID: PMC11056805 DOI: 10.7759/cureus.57276] [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: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a severe reaction to antipsychotic medications characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. Here, we describe the case of a 58-year-old female who presented with altered mental status two days after open reduction and internal fixation of the hip. A rapid response team was called when the patient appeared agitated with increased respiratory demand. After being intubated and moved to the ICU, she became febrile and rigid. A preliminary diagnosis of metabolic encephalopathy of unknown origin was made. Before being transported to the ICU, the patient was given multiple haloperidol doses in addition to her continued at-home medication, paroxetine, for major depressive disorder. The differential diagnosis included a workup for NMS, serotonin syndrome, and infectious processes. Once NMS was determined as the most likely etiology, all antipsychotic and serotonergic medications were discontinued. Then dantrolene and amantadine were administered, which resulted in clinically significant improvement. This case report demonstrates the importance of early identification of and intervention for NMS.
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Affiliation(s)
- Jordan P Fader
- Medicine, College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Madison Walker Evans
- Medicine, College of Osteopathic Medicine, A.T. Still University Kirksville, Kirksville, USA
| | - Austin M Lundgren
- Medicine, College of Osteopathic Medicine, A.T. Still University Kirksville, Kirksville, USA
| | - Trenton B Sigmund
- Medicine, College of Osteopathic Medicine, A.T. Still University Kirksville, Kirksville, USA
| | - Taylor J Allen
- Medicine, Capital Region Medical Center, University of Missouri Health Care, Jefferson, USA
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Caroff SN, Ungvari GS, Gazdag G. Treatment of schizophrenia with catatonic symptoms: A narrative review. Schizophr Res 2024; 263:265-274. [PMID: 36404216 DOI: 10.1016/j.schres.2022.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
Catatonia is a neuropsychiatric syndrome consisting of psychomotor abnormalities caused by a broad range of disorders affecting brain function. While the nosological status of catatonia is no longer restricted to a subtype of schizophrenia in standardized diagnostic systems, the character, course, and clinical significance of catatonia in people with schizophrenia remain unclear. Evidence suggests that catatonia could be a nonspecific state-related phenomenon, a fundamental core symptom dimension of schizophrenia, or a subcortical variant of schizophrenia. Either way, the validity of catatonia in schizophrenia is clinically significant only insofar as it predicts prognosis and response to treatment. Most contemporary clinical trials of antipsychotics have targeted schizophrenia as an overly broad unitary psychosis neglecting any differential response defined by phenomenology or course. However, early naturalistic studies showed that catatonia predicted poor response to first-generation antipsychotics in chronic schizophrenia and case reports cautioned against the risk of triggering neuroleptic malignant syndrome. More recent studies suggest that second-generation antipsychotics, particularly clozapine, may be effective in schizophrenia with catatonic symptoms, while small randomized controlled trials have found that the short-term response to ECT may be faster and more significant. Based on available data, conclusions are limited as to whether antipsychotics are as effective and safe in acute and chronic schizophrenia with catatonic symptoms compared to other treatments and compared to schizophrenia without catatonia. Further studies of the pathophysiology, phenomenology, course and predictive value of catatonia in schizophrenia are worthwhile.
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Affiliation(s)
- Stanley N Caroff
- Behavioral Health Service, Corporal Michael J. Crescenz VA Medical Center and the Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Gabor S Ungvari
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, Australia; Section of Psychiatry, University of Notre Dame, Fremantle, Australia
| | - Gábor Gazdag
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest, Hungary; Department of Psychiatry and Psychotherapy, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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Allonce J, Khan S, Pulford B. Atypical Presentation of Ziprasidone-Induced Neuroleptic Malignant Syndrome: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241262690. [PMID: 39044558 PMCID: PMC11268033 DOI: 10.1177/23247096241262690] [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: 04/03/2024] [Revised: 05/11/2024] [Accepted: 05/31/2024] [Indexed: 07/25/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a severe adverse reaction associated with neuroleptic or antipsychotic drugs. This case report discusses a 43-year-old man with a history of bipolar disorder and polysubstance abuse who presented with altered mental status, autonomic dysfunction, and muscular rigidity. The patient had recently started on ziprasidone, a second-generation antipsychotic, leading to an atypical presentation of NMS. Unlike classic findings associated with NMS induced by first-generation antipsychotics, this case lacked high fever, lead pipe rigidity, or elevated creatine kinase levels greater than 1000 on initial presentation. The delay in diagnosis was attributed to the milder symptoms and absence of typical findings, resulting in extensive diagnostic workup and interventions. The patient responded positively to treatment with lorazepam based on the Woodbury severity stage guidelines. This case underscores the complexity of diagnosing NMS induced by second-generation antipsychotics and highlights the need for awareness and tailored treatment approaches for atypical presentations.
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Affiliation(s)
- John Allonce
- Department of Internal Medicine, Naples Community Hospital, FL, USA
| | - Sikandar Khan
- Department of Internal Medicine, Naples Community Hospital, FL, USA
| | - Brian Pulford
- Department of Internal Medicine, Naples Community Hospital, FL, USA
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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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Karl S, Schönfeldt-Lecuona C, Hirjak D, Sartorius A. [Acute catatonia]. DER NERVENARZT 2023; 94:106-112. [PMID: 36416934 DOI: 10.1007/s00115-022-01407-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Catatonia is an underdiagnosed psychomotor syndrome that can occur in the context of various mental and somatic diseases. Malignant catatonia is particularly relevant in the context of intensive medical care. Clear recommendations in guidelines are missing. OBJECTIVE To present the current state of the diagnosis and treatment of catatonia, especially malignant catatonia. MATERIAL AND METHODS The literature was evaluated with respect to acute catatonic conditions, with a special focus on the differential diagnosis, relevance to intensive medical care and treatment of catatonia. RESULTS In psychiatric inpatients, catatonic syndromes are relatively frequent with a prevalence between 9% and 17%, and in neurological patients somewhat less frequent with a prevalence of 3.3%. There is a clear recommendation for pharmacological treatment with lorazepam. Additional electroconvulsive therapy (ECT) should be considered as early as possible, especially in cases not responding to benzodiazepines. Response rates to ECT have been shown to be 80-100%. In malignant catatonia, ECT should be performed immediately as an emergency indication. CONCLUSION Several factors lead to the underdiagnosis of catatonia. It is problematic that even life-threatening malignant catatonia is often not recognized as such, although there is a mortality of about 50% if untreated. The best treatment outcome is achieved with a combination of benzodiazepines and ECT. The treatment of severe malignant catatonia represents an emergency indication for ECT.
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Affiliation(s)
- Sebastian Karl
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland.
| | | | - Dusan Hirjak
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland
| | - Alexander Sartorius
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland
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Nisijima K. Neuroleptic Malignant Syndrome Improved with Intramuscular Administration of the Anticholinergic Agent, Biperiden. Int Med Case Rep J 2023; 16:281-286. [PMID: 37200957 PMCID: PMC10187584 DOI: 10.2147/imcrj.s412619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/06/2023] [Indexed: 05/20/2023] Open
Abstract
Anticholinergic drugs, such as biperiden, benztropine, and diphenhydramine, were used for neuroleptic malignant syndrome (NMS) in the 1980s and 1990s. However, they have not been recommended for pharmacotherapy in NMS since 2000, as they may prevent a decrease in body temperature by suppressing sweating. However, whether anticholinergic drugs actually exacerbate NMS remains unclear. This study highlights the usefulness of anticholinergic drugs, which are no longer attracting attention as current pharmacological treatments for NMS. I treated four NMS patients using anticholinergic drugs. Two patients were treated with biperiden alone, and the other two patients were treated with a combination of biperiden and other drugs, including dantrolene, amantadine, or diazepam. Intramuscular injection of biperiden improved muscle rigidity, tremors, dysphagia, and akinetic mutism. Psychiatrists are familiar with anticholinergic drugs as they are used for antipsychotic-induced akathisia and Parkinsonism. My study suggests that anticholinergic drugs, especially injectable formulations, can be a therapeutic option for NMS.
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Affiliation(s)
- Koichi Nisijima
- Department of Psychiatry, Nasukougen Hospital, Nasu-machi, Tochigi, Japan
- Department of Psychiatry, Jichi Medical University, Shimotuke City, Tochigi, Japan
- Correspondence: Koichi Nisijima, Shimotuke City, Tochigi, 329-0433, Japan, Tel/Fax +81-285-44-2411, Email
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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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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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Edinoff AN, Mohammad-Amin H, Odisho AS. Silent Neuroleptic Malignant Syndrome: A Case Report of Atypical Antipsychotic Induced Elevation of Creatinine Kinase and Altered Mental Status. Health Psychol Res 2022; 10:37530. [PMID: 35999974 PMCID: PMC9392844 DOI: 10.52965/001c.37530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
34-year-old African American male with a diagnosis of schizophrenia was placed on aripiprazole and risperidone for psychosis and mood stabilization. Two days after medication initiation, the patient's mentation was altered and he appeared confused with an elevated creatine kinase (CK) at 7101. Medications were held and CK normalized with IV fluids. Quetiapine was initiated after medical stabilization along with lithium and paliperidone palmitate injections. After the second dose of paliperidone palmitate, the patient's mentation was altered, and repeat CK was 4272. The patient received 4 liters of IV fluid and his mental status returned to baseline. There were two case studies noted that had marked increases in serum CK with risperidone use. The first was in an adolescent who was titrated to a dose of risperidone 3mg/ day but the only abnormality was an increase in his CK levels. The next case report was in a 40-year-old female who was on risperidone 2.5mg /day for one year. She had an intention tremor, minor muscle weakness of the lower extremities with a blood pressure of 140/100 and a pulse of 100. She manifested more clinical signs of possible Neuroleptic Malignant Syndrome (NMS). This case highlights the importance of laboratory investigations when there is a high suspicion of possible NMS. It also highlights that some cases of NMS may only present as altered mental status and increased CK in which quick treatment may lead to the prevention of full-blown clinical manifestations of NMS which could be life-threatening.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital; Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport; Louisiana Addiction Treatment Center
| | - Hamza Mohammad-Amin
- Department of Psychiatry, Louisiana State University Health Science Center Shreveport
| | - Amira S Odisho
- Department of Psychiatry, Louisiana State University Health Science Center Shreveport
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Abstract
Accurate diagnosis and appropriate treatment of tardive dyskinesia (TD) are imperative, as its symptoms can be highly disruptive to both patients and their caregivers. Misdiagnosis can lead to incorrect interventions with suboptimal or even deleterious results. To aid in the identification and differentiation of TD in the psychiatric practice setting, we review its clinical features and movement phenomenology, as well as those of other antipsychotic-induced movement disorders, with accompanying links to illustrative videos. Exposure to dopamine receptor blocking agents (DRBAs) such as antipsychotics or antiemetics is associated with a spectrum of movement disorders including TD. The differential diagnosis of TD is based on history of DRBA exposure, recent discontinuation or dose reduction of a DRBA, and movement phenomenology. Common diagnostic challenges are the abnormal behaviors and dyskinesias associated with advanced age or chronic mental illness, and other movement disorders associated with DRBA therapy, such as akathisia, parkinsonian tremor, and tremor related to use of mood stabilizing agents (eg, lithium, divalproex). Duration of exposure may help rule out acute drug-induced syndromes such as acute dystonia or acute/subacute akathisia. Another important consideration is the potential for TD to present together with other drug-induced movement disorders (eg, parkinsonism, parkinsonian tremor, and postural tremor from mood stabilizers) in the same patient, which can complicate both diagnosis and management. After documentation of the phenomenology, severity, and distribution of TD movements, treatment options should be reviewed with the patient and caregivers.
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Takenouchi H, Anno T, Kimura Y, Kawasaki F, Shirai R, Kaneto H, Kurokawa K, Tomoda K. Case Report: A Patient With Neuroleptic Malignant Syndrome, Water Intoxication and Hyponatremia Associated With Severe Cerebral Edema and Coma. Front Endocrinol (Lausanne) 2022; 13:822679. [PMID: 35360072 PMCID: PMC8960374 DOI: 10.3389/fendo.2022.822679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Water intoxication is typically caused by primary or psychogenic polydipsia that potentially may lead to fatal disturbance in brain functions. Neuroleptic malignant syndrome (NMS) is a serious complication induced by administration of antipsychotics and other psychotropic drugs. The combination of inappropriate secretion of antidiuretic hormone (SIDAH), NMS and rhabdomyolysis have been rarely reported. Our patient also developed severe water intoxication. CASE PRESENTATION Herein we report a comatose case of NMS complicated with water intoxication, syndrome of SIADH and rhabdomyolysis. This patient had severe cerebral edema and hyponatremia that were improved rapidly by the correction of hyponatremia within a couple of days. CONCLUSIONS Malignant neuroleptic syndrome water intoxication, SIADH and rhabdomyolysis can occur simultaneously. Comatose conditions induced by cerebral edema and hyponatremia can be successfully treated by meticulous fluid management and the correction of hyponatremia.
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Affiliation(s)
- Haruka Takenouchi
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
- *Correspondence: Takatoshi Anno,
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Ryo Shirai
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Katsumi Kurokawa
- Department of Neurology, Kawasaki Medical School, Okayama, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
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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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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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18
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Grant C, Keay JA, Shah BJ, Adeeko B. COVID
‐19, neuroleptic malignant syndrome and psychosis. PROGRESS IN NEUROLOGY AND PSYCHIATRY 2021. [DOI: 10.1002/pnp.713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Calum Grant
- Dr Grant is FY1 Doctor at Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Dr Keay is Fellow in Medical Education, North East London NHS Foundation Trust; Dr Jung Shah is Consultant Psychiatrist, and Dr Adeeko is Consultant Psychiatrist, both at Goodmayes Hospital, North East London NHS Foundation Trust
| | - Jonathan A Keay
- Dr Grant is FY1 Doctor at Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Dr Keay is Fellow in Medical Education, North East London NHS Foundation Trust; Dr Jung Shah is Consultant Psychiatrist, and Dr Adeeko is Consultant Psychiatrist, both at Goodmayes Hospital, North East London NHS Foundation Trust
| | - Bardhan Jung Shah
- Dr Grant is FY1 Doctor at Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Dr Keay is Fellow in Medical Education, North East London NHS Foundation Trust; Dr Jung Shah is Consultant Psychiatrist, and Dr Adeeko is Consultant Psychiatrist, both at Goodmayes Hospital, North East London NHS Foundation Trust
| | - Babatunde Adeeko
- Dr Grant is FY1 Doctor at Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Dr Keay is Fellow in Medical Education, North East London NHS Foundation Trust; Dr Jung Shah is Consultant Psychiatrist, and Dr Adeeko is Consultant Psychiatrist, both at Goodmayes Hospital, North East London NHS Foundation Trust
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19
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Ryu SJ, Lee JY, Lee JH. [Acute Colonic Pseudo-obstruction Induced by Neuroleptic Malignant Syndrome]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:313-316. [PMID: 34158453 DOI: 10.4166/kjg.2021.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 11/03/2022]
Abstract
A colonic pseudo-obstruction is a disorder that causes abdominal distension and abdominal pain similar to a mechanical obstruction, but there are no structural lesions that can obstruct the gastrointestinal tract. This condition can be acute or chronic. An acute colonic pseudo-obstruction, also called Ogilvie's syndrome, is believed to be a condition induced by other causes that are different from a chronic colonic pseudo-obstruction. The pathogenesis involves abnormalities in the autonomic nervous system induced by systemic diseases or medications, and it often improves when the primary causes are treated. On the other hand, a chronic colonic pseudo-obstruction can occur repeatedly without a particular cause. The authors encountered neuroleptic malignant syndrome that caused acute colonic pseudo-obstruction. This paper reports a case with a review of the relevant literature. This is the first case reported in Korea. This case shows that physicians should consider neuroleptic malignant syndrome as a cause of an acute colonic pseudo-obstruction.
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Affiliation(s)
- Sung Ju Ryu
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jong Yoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jong Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
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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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21
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Piacenza F, Ong SK, O’Brien P, Clancy M. Neuroleptic malignant syndrome in a patient with moderate intellectual disability treated with olanzapine: A case report. Clin Case Rep 2021; 9:2404-2408. [PMID: 33936704 PMCID: PMC8077328 DOI: 10.1002/ccr3.4049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
This case demonstrates the challenges encountered in a case of Neuroleptic Malignant Syndrome in a young woman with moderate Intellectual Disability.
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Affiliation(s)
- Francesco Piacenza
- Department of Liaison PsychiatryUniversity Hospital WaterfordWaterfordIreland
| | - Suet Kee Ong
- Department of Liaison PsychiatryUniversity Hospital WaterfordWaterfordIreland
| | | | - Maurice Clancy
- Department of Liaison PsychiatryUniversity Hospital WaterfordWaterfordIreland
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22
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Abstract
Acute presentation of new movement disorders and acute decompensation of chronic movement disorders are uncommon but potentially life-threatening. Inadvertent or purposeful overdose of many psychiatric medications can result in acute life-threatening movement disorders including serotonin syndrome, neuroleptic malignant syndrome, and malignant catatonia. Early withdrawal of potentiating medications, treatment with benzodiazepines and other diagnosis-specific drugs, and providing appropriate supportive care including airway and breathing management, hemodynamic stabilization, fluid resuscitation, and renal support including possible hemodialysis are the mainstays of acute management. Many of these conditions require admission to the neurologic intensive care unit.
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23
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Olson BJ, Dhariwal MS. Neuroleptic Malignant Syndrome: A Case of Unknown Causation and Unique Clinical Course. Cureus 2021; 13:e14113. [PMID: 33927924 PMCID: PMC8075770 DOI: 10.7759/cureus.14113] [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] [Indexed: 11/29/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare, potentially lethal syndrome known to be related to the initiation of dopamine antagonist medications or rapid withdrawal of dopaminergic medications. It is a diagnosis of exclusion with a known sequela of symptoms, but not all patients experience these characteristic symptoms making it difficult at times to diagnose and treat. Herein, we present a unique case of NMS with unclear etiology and a unique clinical course. Our case report also raises the question of whether or not adjusting doses of previously prescribed neuroleptic medications can provoke NMS, providing valuable information for providers treating these complex patients.
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Affiliation(s)
- Brooke J Olson
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
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24
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Caroff SN, Watson CB, Rosenberg H. Drug-induced Hyperthermic Syndromes in Psychiatry. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:1-11. [PMID: 33508784 PMCID: PMC7851465 DOI: 10.9758/cpn.2021.19.1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/02/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Hyperthermia, or extreme elevations in body temperature, can be life-threatening and may be caused by prescription drugs or illegal substances acting at a number of different levels of the neuraxis. Several psychotropic drug classes and combinations have been associated with a classic clinical syndrome of hyperthermia, skeletal muscle hypermetabolism, rigidity or rhabdomyolysis, autonomic dysfunction and altered mental status ranging from catatonic stupor to coma. It is critical for clinicians to have a high index of suspicion for these relatively uncommon drug-induced adverse effects and to become familiar with their management to prevent serious morbidity and mortality. Although these syndromes look alike, they are triggered by quite different mechanisms, and apart from the need to withdraw or restore potential triggering drugs and provide intensive medical care, specific treatments may vary. Clinical similarities have led to theoretical speculations about common mechanisms and shared genetic predispositions underlying these syndromes, suggesting that there may be a common “thermic stress syndrome” triggered in humans and animal models by a variety of pharmacological or environmental challenges.
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Affiliation(s)
- Stanley N Caroff
- Corporal Michael J. Crescenz VA Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Charles B Watson
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Henry Rosenberg
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
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25
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De Berardis D, De Filippis S, Masi G, Vicari S, Zuddas A. A Neurodevelopment Approach for a Transitional Model of Early Onset Schizophrenia. Brain Sci 2021; 11:brainsci11020275. [PMID: 33672396 PMCID: PMC7926620 DOI: 10.3390/brainsci11020275] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/16/2022] Open
Abstract
In the last decades, the conceptualization of schizophrenia has dramatically changed, moving from a neurodegenerative process occurring in early adult life to a neurodevelopmental disorder starting be-fore birth, showing a variety of premorbid and prodromal symptoms and, in relatively few cases, evolving in the full-blown psychotic syndrome. High rates of co-occurring different neurodevelopmental disorders such as Autism spectrum disorder and ADHD, predating the onset of SCZ, and neurobio-logical underpinning with significant similarities, support the notion of a pan-developmental disturbance consisting of impairments in neuromotor, receptive language, social and cognitive development. Con-sidering that many SCZ risk factors may be similar to symptoms of other neurodevelopmental psychi-atric disorders, transition processes from child & adolescent to adult systems of care should include both high risk people as well as subject with other neurodevelopmental psychiatric disorders with different levels of severity. This descriptive mini-review discuss the need of innovative clinical approaches, re-considering specific diagnostic categories, stimulating a careful analysis of risk factors and promoting the appropriate use of new and safer medications.
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Affiliation(s)
- Domenico De Berardis
- Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital “G. Mazzini,” National Health Service (NHS), 64100 ASL 4 Teramo, Italy
- Department of Neurosciences and Imaging, University “G. D’Annunzio”, 66100 Chieti, Italy
- Correspondence:
| | - Sergio De Filippis
- Department of Neuropsychiatry, Villa von Siebenthal Neuropsychiatric Hospital and Clinic, Genzano di Roma, 100045 Rome, Italy;
| | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, 56128 Pisa, Italy;
| | - Stefano Vicari
- Department of Life Sciences and Publich Health, Catholic University, 00135 Rome, Italy;
- Child & Adolescent Psychiatry, Bambino Gesù Children’s Hospital, 00168 Rome, Italy
| | - Alessandro Zuddas
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Sciences, University of Cagliari and “A Cao” Paediatric Hospital, “G Brotzu” Hospital Trust, 109134 Cagliari, Italy;
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26
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Sedhai YR, Atreya A, Phuyal P, Basnyat S, Pokhrel S. Case Report: Ziprasidone induced neuroleptic malignant syndrome. F1000Res 2021; 10:124. [PMID: 33763203 PMCID: PMC7953912 DOI: 10.12688/f1000research.51094.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/20/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a well-recognized neurologic emergency. It presents with classic features including hyperthermia, autonomic instability, muscle hypertonia, and mental status changes. The syndrome is potentially fatal and is associated with significant morbidity due to complications such as rhabdomyolysis, acute kidney injury, and ventricular arrhythmias due to the trans-cellular electrolyte shift. NMS is conventionally associated with the first-generation antipsychotic agents, however, has been described with the use of atypical and novel antipsychotics including Ziprasidone. A case of NMS with Ziprasidone use at the therapeutic dose is reported here.
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Affiliation(s)
- Yub Raj Sedhai
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, South Hill, VA, USA
| | - Alok Atreya
- Lumbini Medical College, Lumbini, Palpa, 32500, Nepal
| | - Prabin Phuyal
- Department of Internal Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Soney Basnyat
- Division of Geriatric Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sagar Pokhrel
- Department of Critical Care Medicine, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
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27
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Hernandez SD, Marotta DA, Goteti R. Atypical Neuroleptic Malignant Syndrome in the Setting of Quetiapine Overdose: A Case Report and Review of the Literature. Cureus 2021; 13:e12602. [PMID: 33585092 PMCID: PMC7872006 DOI: 10.7759/cureus.12602] [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: 11/07/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare and life-threatening emergency. The condition is largely iatrogenic and is often precipitated by medications such as antipsychotics. First-generation antipsychotics are more likely to cause NMS than second-generation antipsychotics. The literature lacks an objective measure for NMS diagnosis. Instead, the diagnosis relies largely on the recognition of characteristic symptoms in the presence of an inciting medication. Additional challenges exist with concomitant disease processes and toxicities that may distort the clinical picture. Here, we report a case of a 44-year-old Caucasian man who presented with atypical NMS in the setting of quetiapine overdose. The patient remained uncharacteristically afebrile throughout his admission. Although the patient recovered, extended delays in identification and management can contribute to an increased risk of morbidity and mortality.
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Affiliation(s)
| | - Dario A Marotta
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA.,Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, USA
| | - Ravitej Goteti
- Department of Internal Medicine, Southeast Health, Dothan, USA
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29
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Fukushima K, Aramaki Y, Ichikawa Y, Isshiki Y, Sawada Y, Nakajima J, Kambe M, Murata M, Aoki M, Oshima K. Reversible brain imaging findings with a severe neurological prognosis of neuroleptic malignant syndrome. Heliyon 2020; 6:e05374. [PMID: 33163660 PMCID: PMC7610276 DOI: 10.1016/j.heliyon.2020.e05374] [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] [Received: 05/18/2020] [Revised: 08/27/2020] [Accepted: 10/26/2020] [Indexed: 10/26/2022] Open
Abstract
Neuroleptic malignant syndrome is a rare but life-threatening disorder associated with the use of neuroleptic drugs, and is characterized by fever, altered mental status, muscle rigidity, autonomic instability, myoclonus, elevated creatine kinase levels, rhabdomyolysis, and leukocytosis. Previous reports have shown that most patients with neuroleptic malignant syndrome recover without neurologic sequelae. Some patients with neuroleptic malignant syndrome show reversible magnetic resonance imaging (changes in the brain. The severe neurological impairments do not persist in neuroleptic malignant syndrome patients with reversible lesions. Here, we describe a 66-year-old Japanese woman who was diagnosed with septic shock secondary to obstructive pyelonephritis. She was administered haloperidol for delirium and developed neuroleptic malignant syndrome. Magnetic resonance imaging of the brain showed diffuse hyperintense signals in the cerebellar cortex, cerebellar dentate nucleus, superior cerebellar peduncle, and thalamus on T2-weighted imaging or fluid-attenuated inversion recovery, and in the bilateral substantia nigra and bilateral globus pallidus on diffusion-weighted imaging. Subsequently, the signal intensities of the cerebellar and thalamic lesions diminished and the basal ganglia lesions disappeared, but the severe neurologic sequelae remained. The cerebellum is reportedly particularly sensitive to thermal damage because Purkinje cells are believed to be vulnerable to heat. Although brain imaging studies revealed reversible changes, her disturbance of consciousness was prolonged. Therefore, brain magnetic resonance imaging findings might not reflect the neurologic prognosis in patients with neuroleptic malignant syndrome.
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Affiliation(s)
- Kazunori Fukushima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuto Aramaki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yumi Ichikawa
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuta Isshiki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yusuke Sawada
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Jun Nakajima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masahiko Kambe
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masato Murata
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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30
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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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31
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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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Caroff SN. Risk of Neuroleptic Malignant Syndrome with Vesicular Monoamine Transporter Inhibitors. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2020; 18:322-326. [PMID: 32329312 PMCID: PMC7242105 DOI: 10.9758/cpn.2020.18.2.322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 12/04/2022]
Abstract
Objective Vesicular monoamine transporter-2 (VMAT2) inhibitors have been proven to be effective for the treatment of tardive dyskinesia and their use is likely to increase. The evidence base of published clinical reports was reviewed to evaluate the possible risk of neuroleptic malignant syndrome (NMS) with these drugs. Methods Pubmed, Embase, Web of Science and PsycINFO databases were queried for all years using terms for “neuroleptic malignant syndrome”, “hyperthermia” AND “vesicular monoamine transporter inhibitors”, “reserpine”, “tetrabenazine”, “valbenazine” or “deutetrabenazine” Results Thirteen clinical cases, ten of which involved tetrabenazine, were identified in which VMAT2 inhibitors were prescribed in patients with current or past NMS episodes. In most cases, the association was confounded by limited reporting of clinical data, variable temporal correlation with VMAT2 inhibitors, polypharmacy with antipsychotics, and uncertain differential diagnoses. Conclusion While rare cases of NMS meeting consensus criteria have been reported primarily with tetrabenazine, the risk with recently developed VMAT2 inhibitors may be even less. Evidence of causality of NMS with VMAT2 inhibitors is confounded by concomitant treatment with antipsychotics and diagnostic uncertainties in patients susceptible to basal ganglia dysfunction. Nevertheless, clinicians should remain vigilant for early signs of NMS in all patients treated with any drugs that affect brain dopamine activity.
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Affiliation(s)
- Stanley N Caroff
- Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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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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Electroconvulsive Therapy as a Corrector for Certain Side Effects of Antipsychotic Therapy. ACTA BIOMEDICA SCIENTIFICA 2020. [DOI: 10.29413/abs.2020-5.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Zhao J, Xu G, Feng C, Chen Y, Kang Y, Liu F, Ma W. Trihexyphenidyl induced malignant hyperthermia in a patient with Parkinson's disease complicated with pneumonia: A case report. Medicine (Baltimore) 2020; 99:e20129. [PMID: 32443324 PMCID: PMC7254568 DOI: 10.1097/md.0000000000020129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Drug-induced fever is easy to overlook in respiratory departments. High fever is a rare side effect of trihexyphenidyl, which can be used clinically to treat Parkinson's disease. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a group of clinical syndromes caused by various diseases, resulting in water retention and refractory hyponatremia. However, pneumonia combined with malignant hyperthermia and SIADH has rarely been reported. We describe an unusual case of malignant hyperthermia and refractory hyponatremia due to trihexyphenidyl adverse reaction. PATIENT CONCERNS Fifty-five-year-old male with pneumonia presented with malignant hyperthermia and refractory hyponatremia has a history of Parkinson's disease. DIAGNOSIS Early considerations related the described hyperthermia findings to the manifestations of pneumonia. However, the last findings were due to trihexyphenidyl adverse reaction. INTERVENTIONS Broad-spectrum antibiotics, oral and intravenous supplement of concentrated sodium chloride, drug, and physical cooling. OUTCOMES The patient survived. During the 3-month follow up, the patient was no recurrence of fever or hyponatremia. CONCLUSION High fever and SIADH can be a rare adverse reaction to trihexyphenidyl. Therefore, possible drug factors should be considered in the case. Consideration of other possible causes can improve early diagnosis and treatment of patients with fever of unknown origins.
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Affiliation(s)
- Jun Zhao
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology
- Guangzhou First People's Hospital, Guangzhou Medical University
| | - Gang Xu
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology
- Guangzhou First People's Hospital, Guangzhou Medical University
| | - Congrui Feng
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology
- Guangzhou First People's Hospital, Guangzhou Medical University
| | - Yuluo Chen
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology
- Guangzhou First People's Hospital, Guangzhou Medical University
| | - Yanhong Kang
- Department of Respiration, The First Affiliated Hospital/School of Clinical Medicine of Guangdong Pharmaceutical University, Guangzhou, China
| | - Feng Liu
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology
- Guangzhou First People's Hospital, Guangzhou Medical University
| | - Wei Ma
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology
- Guangzhou First People's Hospital, Guangzhou Medical University
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Bobolakis I. Neuroleptic malignant syndrome following tiapride treatment of clonazepam withdrawal. Eur Psychiatry 2020; 10:110-1. [DOI: 10.1016/0924-9338(96)80322-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/1994] [Accepted: 05/24/1994] [Indexed: 10/18/2022] Open
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Ullah W, Cheema MA, Ashfaq A, Mukhtar M, Ali Z, Ur Rashid M, Figueredo V. A rare association of Takotsubo cardiomyopathy with neuroleptic malignant syndrome. J Community Hosp Intern Med Perspect 2020; 10:133-137. [PMID: 32850048 PMCID: PMC7425628 DOI: 10.1080/20009666.2020.1742522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Waqas Ullah
- Internal Medicine, Abington, Jefferson Health, Abington, PA, USA
| | | | - Ammar Ashfaq
- Internal Medicine, Abington, Jefferson Health, Abington, PA, USA
| | - Maryam Mukhtar
- Rawal Pindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Zain Ali
- Internal Medicine, Abington, Jefferson Health, Abington, PA, USA
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Abstract
PURPOSE/BACKGROUND Neuroleptic malignant syndrome (NMS) has been described with most antipsychotics, most commonly first generation. Clozapine has also been associated with NMS. METHODS/PROCEDURES We conducted a systematic review to identify all studies investigating or describing (a) clozapine rechallenge following suspected NMS associated with clozapine, (b) clozapine use after suspected NMS associated with another antipsychotic, and (c) rechallenge with nonclozapine antipsychotics after suspected clozapine-associated NMS. FINDINGS/RESULTS We identified 51 reports detailing 67 cases. Thirty-eight described clozapine administration after NMS on a nonclozapine antipsychotic; 12 described a clozapine rechallenge after an NMS on clozapine monotherapy; and 17 described the use of nonclozapine antipsychotics after an NMS on clozapine. The outcome of clozapine rechallenge was favorable (no recurrence of NMS) in 92% (n = 11) of cases after an NMS on clozapine and in 79% (n = 30) of those prescribed clozapine following NMS on a nonclozapine antipsychotic. Most (82%; n = 14) cases after NMS on clozapine had no recurrence of NMS on receiving a nonclozapine antipsychotic.No mortality was reported with any of these interventions. IMPLICATIONS/CONCLUSIONS Our findings suggest that rechallenge following clozapine NMS is possible, and with careful risk-benefit analysis consideration, a clozapine rechallenge can be made. A publication bias in favor of cases in which rechallenge was successful is probable and is an important limitation.
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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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Sabharwal P, Chauhan R, Mittal G, Jain A. Importance of preanesthetic evaluation in emergency: Are we in haste. J Anaesthesiol Clin Pharmacol 2020; 36:273-274. [PMID: 33013051 PMCID: PMC7480287 DOI: 10.4103/joacp.joacp_216_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022] Open
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Abstract
OBJECTIVES Neuroleptic malignant syndrome (NMS) is an uncommon condition associated with significant morbidity and mortality. Data on treatment interventions are limited. In this case series, we sought to describe all NMS cases requiring ECT from a large academic institution over a nearly 2-decade period. METHODS We retrospectively identified all patients with NMS who were treated with ECT over a 17-year period. Patients were included in the study based on chart review using the International Consensus Diagnostic Criteria for NMS. Data were collected related to clinical findings, treatment course, and response to ECT. RESULTS We identified 15 patients meeting the inclusion criteria. Most patients had neurocognitive or schizophrenia spectrum disorders and developed NMS after exposure to multiple antipsychotic drugs. All patients received bitemporal ECT after failed pharmacotherapy for NMS. Electroconvulsive therapy was well tolerated and resulted in a remission rate of 73.3% (n = 11). Patients showed early initial response to ECT (mean of 4.2 treatments), but an average of 17.7 treatments was necessary to minimize recurrence of catatonic signs. One patient died after interruption of the index course of ECT because of severe infection, and another was discharged to hospice care after limited response. These cases highlight the lethality of NMS and its complications despite aggressive treatment measures. CONCLUSIONS Bitemporal ECT was well tolerated and effective in treating NMS refractory to pharmacotherapy. We suggest that ECT be considered early in cases of NMS that are refractory to pharmacological interventions, especially if the underlying condition is also responsive to ECT.
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Affiliation(s)
- Nicholas Morcos
- From the Michigan Medicine Department of Psychiatry, The University of Michigan, Ann Arbor, MI
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42
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Affiliation(s)
- Stanley N Caroff
- The Department of Psychiatry, Corporal Michael J. Crescenz Veterans Affairs Medical Center and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
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43
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Hirjak D, Sartorius A, Kubera KM, Wolf RC. [Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 2 : Catatonic symptoms and neuroleptic malignant syndrome]. DER NERVENARZT 2019; 90:12-24. [PMID: 30128733 DOI: 10.1007/s00115-018-0581-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In rare cases, pharmacotherapy in schizophrenic psychoses can be associated with life-threatening antipsychotic-induced movement disorders. The two most severe complications are antipsychotic-associated catatonic symptoms (ACS) and neuroleptic malignant syndrome (NMS). Although both constellations necessitate rapid medical care, the diagnosis is still a clinical challenge. Although there is no established treatment of ACS (here designated as a specific subtype of catatonic symptoms), an attempt should be made with benzodiazepines and memantine can also be helpful. In severe drug-refractory cases electroconvulsive therapy (ECT) can be indicated. The NMS represents a life-threatening constellation that frequently requires intensive care unit treatment. The medicinal treatment with benzodiazepines, bromocriptine, amantadine, dantrolene and/or ECT is also advocated. Finally, this review article also summarizes the currently available literature for treatment of genuine catatonic symptoms. In conclusion, the abovementioned clinical syndromes must be rapidly recognized and treated. Early recognition and treatment of these movement disorders can under certain circumstances be lifesaving and favorably influence the later clinical outcome.
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Affiliation(s)
- D Hirjak
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland.
| | - A Sartorius
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - K M Kubera
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
| | - R C Wolf
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
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44
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Velosa A, Neves A, Barahona-Corrêa JB, Oliveira-Maia AJ. Neuroleptic malignant syndrome: a concealed diagnosis with multitreatment approach. BMJ Case Rep 2019; 12:12/6/e225840. [PMID: 31213433 DOI: 10.1136/bcr-2018-225840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
While neuroleptic malignant syndrome (NMS) is typically characterised by delirium, motor rigidity, fever and dysautonomia, the syndrome is not pathognomonic, and NMS remains a diagnosis of exclusion. Here, we describe the case of a 44-year-old woman, with no relevant psychiatric history, admitted to a nephrology unit due to acute renal failure. After administration of antipsychotics, she presented with mental status alteration, generalised tremor, rigidity and autonomic nervous system dysfunction. Fever and rhabdomyolysis, however, were not prominent, and NMS was not considered initially in the differential diagnosis. The resulting delay in diagnosis, with continued administration of antipsychotics, led to progressive clinical deterioration. Once NMS was considered, however, antipsychotics were withdrawn and the patient was treated with electroconvulsive therapy (ECT), followed by administration of a dopamine receptor agonist, with close to full remission of all symptoms. Importantly, during outpatient follow-up, sustained mild and asymmetric tremor and rigidity was noted, leading to a diagnosis of Parkinson's disease. While this raises questions regarding differential diagnosis between NMS in Parkinson's disease, versus worsening of Parkinson's disease due to antipsychotic treatment, the former is supported by the acute and rapidly progressive onset of exuberant autonomic dysfunction and clouded conscience, after administration of a neuroleptic. Ultimately, a definitive distinction between these two alternatives for diagnosis of the inaugural neurological presentation in this patient is not possible. Nevertheless, we believe this case illustrates that NMS can be easily missed, particularly in atypical cases, delaying appropriate treatment, and that a flexible multimodal treatment approach, involving ECT, should be considered for complex clinical cases. Furthermore, it also underlines the importance of post-NMS follow-up, to investigate underlying neurological or medical disorders, particularly in those patients who do not have a full recovery.
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Affiliation(s)
- Ana Velosa
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - António Neves
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,Department of Psychiatry and Mental Health, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - J Bernardo Barahona-Corrêa
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,Department of Psychiatry and Mental Health, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.,Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Albino J Oliveira-Maia
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,Department of Psychiatry and Mental Health, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.,Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
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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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Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018; 17:341-356. [PMID: 30192094 PMCID: PMC6127750 DOI: 10.1002/wps.20567] [Citation(s) in RCA: 263] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.
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Affiliation(s)
- T Scott Stroup
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gray
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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47
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Agbonrofo PI, Osakue JE. Neuroleptic malignant syndrome in a young adult female at the university of Benin Teaching Hospital: a case report. Afr Health Sci 2018; 18:786-789. [PMID: 30603012 PMCID: PMC6306994 DOI: 10.4314/ahs.v18i3.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Neuroleptic malignant syndrome is a rare but life-threatening idiosyncratic complication following the use of antipsychotic agents, anaesthesia and surgery. It is characterized by hyperthermia, muscle rigidity, autonomic disturbances and mental state alterations. Case A 31 year old female weighing 60kg received a depot preparation of Fluphenazine on account of depression with psychotic features observed two days prior to elective Cholecystectomy under general anaesthesia. Surgery and anaesthesia were essentially uneventful. Forty eight hours post-operatively, the patient developed features suggestive of neuroleptic malignant syndrome complicated by aspiration pneumonitis. This necessitated her admission into the intensive care unit. She had prolonged stay in the intensive care unit, where she was mechanically ventilated, developed deep venous thrombosis of the left upper limb and required tracheostomy on account of prolonged endotracheal intubation. Patient recovered fully following bromocriptine and dantrolene therapy. She was discharged home after 60 days on admission and has remained in good health. Conclusion Though rare, neuroleptic malignant syndrome can occur in young adult females following use of antipsychotics, anaesthesia and surgery. Its clinical course can be prolonged and distressing with the use of depot preparations. Early diagnosis and prompt supportive measures are essential to reduce morbidity and mortality.
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Affiliation(s)
- Peter I Agbonrofo
- Department of Surgery, University of Benin Teaching Hospital, PMB 1111, Benin City, Nigeria. ; . Tel:+234 802-829-6343
| | - John E Osakue
- Department of Anaesthesiology, University of Benin Teaching Hospital, PMB 1111, Benin City, Nigeria. . Tel:+234 806-036-2070, +234 809-111-4193
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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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A Case of Neuroleptic Malignant Syndrome in a Profoundly Intellectually Disabled Patient with Successful Reintroduction of Antipsychotic Therapy with Quetiapine. Case Rep Psychiatry 2018; 2018:7045106. [PMID: 30112240 PMCID: PMC6077586 DOI: 10.1155/2018/7045106] [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: 01/23/2018] [Accepted: 05/14/2018] [Indexed: 11/17/2022] Open
Abstract
Neuroleptic Malignant Syndrome (NMS) is a rare condition clinically characterized by muscle rigidity, hyperthermia, autonomic instability, and acute mental status change. NMS is most often associated with use of high-potency first-generation antipsychotic medications; though, other neuroleptics have been implicated as well. NMS can be fatal with estimated mortality rates as high as 20%. Patients experiencing certain severe complications, including renal failure, have been associated with mortality as high as 50%, stressing the need for early recognition and treatment. Here we present the case of a 54-year-old male that initially presented with symptoms suspicious for sepsis, but who eventually developed a clinical picture consistent with NMS. We describe the diagnostic and treatment process leading to symptom remission. We then discuss our decision to reintroduce an atypical antipsychotic agent, quetiapine. This case illustrates the importance of early recognition of the signs and symptoms of NMS and the need to initiate treatment promptly in order to prevent complications, including death. This case also highlights the decision to resume antipsychotic pharmacotherapy after adequate resolution of NMS, demonstrating that it can be done so safely if started at low doses coupled with intensive monitoring of the patient.
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50
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Rocker JA, Oestreicher J. Focused Medical Assessment of Pediatric Behavioral Emergencies. Child Adolesc Psychiatr Clin N Am 2018; 27:399-411. [PMID: 29933790 DOI: 10.1016/j.chc.2018.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is no uniformly accepted standard of care for medical clearance of pediatric patients with psychiatric complaints. Emerging data argue for a thorough history and physical examination and against routine laboratory testing. The differential diagnosis of patients presenting with psychiatric health complaints is extensive and includes both medical and psychiatric disorders. Providers should remain mindful of anchoring or diagnosis momentum bias when caring for these patients, especially patients with a psychiatric history.
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Affiliation(s)
- Joshua A Rocker
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center of New York, Northwell Health, 269-01 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Jeffrey Oestreicher
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center of New York, Northwell Health, 269-01 76th Avenue, New Hyde Park, NY 11040, USA
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