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Sarmiento RJC, Diestro JDB, Antonio AKD, Prado MB, Adiao KJB, Dioquino-Maligaso CP. Neuroleptic Malignant Syndrome in a Patient With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Case Report and Review of Related Literature. Neurohospitalist 2022; 12:80-85. [PMID: 34950391 PMCID: PMC8689546 DOI: 10.1177/19418744211002978] [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: 01/03/2023] Open
Abstract
INTRODUCTION Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe but treatable disease that presents with symptoms similar to neuroleptic malignant syndrome (NMS). CASE REPORT We describe a 28-year old female who initially presented with headaches, behavioral changes, anxiety, lip tremors, and rigidity of extremities. She was prescribed with olanzapine and later manifested with neuroleptic malignant syndrome symptoms such as decrease in sensorium, muscle rigidity, hyperthermia and tachycardia. Further investigation showed presence of bilateral ovarian teratoma and anti-NMDAR antibodies in her serum and cerebrospinal fluid. Symptoms resolved after intravenous high-dose methylprednisolone, bilateral oophoro-cystectomy, and intravenous immunoglobulin administration. Overlapping pathological mechanisms of anti- NMDAR encephalitis and NMS were discussed. Ten patients with anti- NMDAR encephalitis and NMS were noted in a review of literature. Prognosis was favorable and intervention ranged from supportive to methylprednisolone and intravenous immunoglobulin administration, plasma exchange and teratoma resection. CONCLUSION Anti- NMDAR encephalitis patients are at risk for NMS due to antipsychotic intolerance and other interrelated pathophysiological mechanisms. The overlap between the signs and symptoms of anti-NMDAR encephalitis and NMS poses a diagnostic dilemma and warrants a careful investigation and management.
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Affiliation(s)
- Robert Joseph C. Sarmiento
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines,Robert Joseph C. Sarmiento, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, 1000 Manila, Philippines.
| | - Jose Danilo B. Diestro
- Département de radiologie, radio-oncologie et médecine nucléaire, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montreal, Canada
| | - Athena Kate D. Antonio
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mario B. Prado
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Karen Joy B. Adiao
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Carissa Paz Dioquino-Maligaso
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines,National Poison Management and Control Center, University of the Philippines, Philippine General Hospital, Manila, Philippines
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Serrano WC, Maldonado J. The Use of Physostigmine in the Diagnosis and Treatment of Anticholinergic Toxicity After Olanzapine Overdose: Literature Review and Case Report. J Acad Consult Liaison Psychiatry 2021; 62:285-297. [PMID: 34102130 DOI: 10.1016/j.jaclp.2020.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/24/2020] [Accepted: 12/27/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Second-generation antipsychotic agents are commonly used by clinicians for the treatment of various psychiatric and medical conditions. Despite their presumed safety, an overdose with olanzapine may lead to the development of anticholinergic toxicity. The anticholinergic toxidrome is characterized by both central and peripheral physical findings. Central anticholinergic syndrome, a term used to describe the symptoms that arise from reduced cholinergic activity in the central nervous system, is characterized primarily by signs and symptoms consistent with hyperactive delirium. Signs of peripheral anticholinergia include mydriasis and blurred vision, tremors, ataxia, fever/hyperthermia, flushed and dry skin, dry oral mucosa, decreased bowel sounds, constipation, and urinary retention, among other symptoms. In extreme cases, central anticholinergic syndrome can be associated with seizures, coma, respiratory failure, and cardiovascular collapse. OBJECTIVE To provide scientific evidence regarding the efficacy and safety of physostigmine use in cases of anticholinergic toxicity. METHODS We conducted a comprehensive review of the published literature on the symptoms, diagnosis, and treatment of anticholinergic toxicity. RESULTS Currently the recommended treatment for olanzapine overdose, as is the case of most severe anticholinergic toxicity cases, involves supportive care, along with cardiac, neurological, and respiratory status monitoring. In addition, we detail the symptoms characteristic of anticholinergic toxicity, using the case of a patient experiencing central anticholinergic syndrome after an overdose with olanzapine. CONCLUSION Physostigmine, a tertiary acetylcholinesterase inhibitor, can be used to assist in the both the diagnosis and management of severe anticholinergic toxicity associated with an olanzapine overdose, which might be applicable to the antimuscarinic toxidrome associated with the ingestion of agents with significant anticholinergic activity.
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Affiliation(s)
- Wilmarie Cidre Serrano
- Department of Psychiatry & Behavioral Sciences, Stanford University 401 Quarry Road, Stanford, CA
| | - Jose Maldonado
- Department of Psychiatry & Behavioral Sciences, Stanford University 401 Quarry Road, Stanford, CA.
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Aran G, Hicks C, Demand A, Johnson AL, Beaman J, Bailey Y, Haught M, Lane A, Sinnett P, Vassar M. Treating schizophrenia: the quality of evidence behind treatment recommendations and how it can improve. BMJ Evid Based Med 2020; 25:138-142. [PMID: 31672699 DOI: 10.1136/bmjebm-2019-111233] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To assess the methodological and reporting quality of systematic reviews that comprise the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Schizophrenia and to determine the extent to which results from Cochrane systematic reviews published after guideline development would alter or confirm current recommendations. PARTICIPANTS Systematic reviews that underpinned recommendations in the APA guidelines and Cochrane systematic reviews. MAIN OUTCOME Three independent reviewers scored all systematic reviews referenced in the guideline for quality and reporting using AMSTAR and PRISMA checklist, respectively. Items in both tools were individually graded and compared to identify consistently low-performing areas within the systematic reviews. Post hoc analysis of the Cochrane systematic reviews since the latest revision of APA's guidelines were performed to determine whether their findings were congruent with recent recommendations. RESULTS The mean score of the 57 reviews on the PRISMA checklist was 70%. The mean AMSTAR score was 6.8, correlating with a moderate quality score. Post hoc analysis revealed that 171 Cochrane reviews had been published since the APA guideline release. Only half of the reviews of pharmacological interventions confirmed current recommendations. CONCLUSIONS AND RELEVANCE The methodological quality of the systematic reviews included in the APA guideline was deficient in key areas. Our study brings to light the importance of using high-quality evidence in the development of clinical practice guidelines. An updated APA guideline (last updated in 2009) is necessary to provide the highest quality treatment recommendations for clinicians in the management of schizophrenia. TRIAL REGISTRATION NUMBER UMIN-CTR, UMIN000023099.
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Affiliation(s)
- Greg Aran
- Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Chandler Hicks
- Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Alexander Demand
- Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Austin L Johnson
- Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Jason Beaman
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
- Department of Psychiatry, Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Yakiji Bailey
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Melissa Haught
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Aaron Lane
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Philip Sinnett
- Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
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Heat stroke during treatment with olanzapine, trihexyphenidyl, and trazodone in a patient with schizophrenia. Acta Neuropsychiatr 2015; 27:380-5. [PMID: 26503496 DOI: 10.1017/neu.2015.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Heat stroke is a medical emergency. Psychiatric patients are particularly susceptible to heat stroke. Therefore, awareness and preventive measures of heat stroke are important for both clinicians and patients. Case description A 49-year-old man with schizophrenia, who was under maintenance treatment with olanzapine 20 mg/day, trihexyphenidyl 4 mg/day, and trazodone 50 mg/day, suffered from heat stroke in a heat wave and required intensive care. He recovered with the medical treatment provided. Discussion Several factors could have contributed to the impaired thermoregulation and the occurrence of heat stroke in this case: schizophrenia, the psychotropic regimen, and lack of preventive measures. Possible differential diagnoses of heat stroke in this case include infection, neuroleptic malignant syndrome, and serotonin syndrome. CONCLUSION Heat stroke can occur during the maintenance treatment of olanzapine, trihexyphenidyl, and trazodone for schizophrenia. Clinicians should be proactive to reduce the risk of heat stroke in psychiatric patients.
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Nabih FO, Benali A, Adali I, Manoudi F, Asri F. [Association of atypical neuroleptics with anticonvulsants and malignant syndrome. Report of 2 cases]. Pan Afr Med J 2014; 18:220. [PMID: 25422695 PMCID: PMC4239457 DOI: 10.11604/pamj.2014.18.220.4868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 07/04/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Fadoua Oueriagli Nabih
- Service de Psychiatrie, Hôpital Militaire Avicenne, Equipe de Recherche pour la Santé Mentale, Université Caddi Ayyad, Marrakech, Maroc
| | - Abdeslam Benali
- Service de Psychiatrie, Hôpital Militaire Avicenne, Equipe de Recherche pour la Santé Mentale, Université Caddi Ayyad, Marrakech, Maroc
| | - Imane Adali
- Service de Psychiatrie, Hôpital Militaire Avicenne, Equipe de Recherche pour la Santé Mentale, Université Caddi Ayyad, Marrakech, Maroc
| | - Fatiha Manoudi
- Service de Psychiatrie, Hôpital Militaire Avicenne, Equipe de Recherche pour la Santé Mentale, Université Caddi Ayyad, Marrakech, Maroc
| | - Fatima Asri
- Service de Psychiatrie, Hôpital Militaire Avicenne, Equipe de Recherche pour la Santé Mentale, Université Caddi Ayyad, Marrakech, Maroc
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Butwicka A, Krystyna S, Retka W, Wolańczyk T. Neuroleptic malignant syndrome in an adolescent with CYP2D6 deficiency. Eur J Pediatr 2014; 173:1639-42. [PMID: 24253372 PMCID: PMC4245487 DOI: 10.1007/s00431-013-2208-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 10/25/2013] [Indexed: 11/28/2022]
Abstract
We describe a patient with dystonia and psychotic symptoms treated with standard doses of antipsychotics, who developed neuroleptic malignant syndrome (NMS). A 16-year-old male with a history of misuse of dextromethorphan and pseudoephedrine for recreational purpose presented with dystonia and a psychotic episode. Following continuous treatment with olanzapine (10 mg/day), repeated injections of levomepromazine (37.5 mg/day), and a single injection of haloperidol (2.5 mg), the patient developed NMS. Muscular rigidity, fever (up to 41 °C), hypotension (100/70 mmHg), tachycardia (120 beats per minute), tachypnea (26 breaths per minute), elevated leukocyte count (up to 16.6 × 10(3)/μL), and elevated serum creatinine phosphokinase (CPK) (up to 15,255 U/L) were observed. A diagnosis of NMS was made according to the DSM-IV TR criteria. Genotyping revealed that he was homozygous for a non-functional CYP2D6*4 allele. The case highlights the importance of therapeutic drug monitoring in identification and differentiation of drug-induced effects in psychiatric disorder to prevent NMS and its complications. In addition, genotyping of CYP2D6 might be considered in patients with symptoms suggestive of drug toxicity who are treated with neuroleptics metabolized via the CYP2D6 pathway, as carriage of one or more non-functional alleles may increase the risk for adverse reactions, such as NMS.
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Affiliation(s)
- Agnieszka Butwicka
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, PO Box 281, 171 77, Stockholm, Sweden,
| | - Szymańska Krystyna
- Department of Child Psychiatry, Medical University of Warsaw, 24 Marszałkowska St., 00-575 Warsaw, Poland
| | - Włodzimierz Retka
- Department of Paediatric Anaesthesia, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Wolańczyk
- Department of Child Psychiatry, Medical University of Warsaw, 24 Marszałkowska St., 00-575 Warsaw, Poland
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Trollor JN, Chen X, Chitty K, Sachdev PS. Comparison of neuroleptic malignant syndrome induced by first- and second-generation antipsychotics. Br J Psychiatry 2012; 201:52-6. [PMID: 22626633 DOI: 10.1192/bjp.bp.111.105189] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reports of neuroleptic malignant syndrome (NMS) induced by second-generation antipsychotic drugs highlight a propensity for atypical clinical presentations. AIMS To systematically compare the clinical profile of NMS induced by first- (1G-NMS) and second-generation antipsychotic drugs (2G-NMS). METHOD The Australian Adverse Drug Reaction Advisory Committee (ADRAC) database was searched to identify individuals with NMS reported between April 1994 and September 2010. The clinical characteristics of 208 people with NMS induced by monotherapy with first- or second-generation antipsychotic drugs, as well as presenting features of NMS, were compared. RESULTS The individuals with 2G-NMS were younger and more likely to have a psychotic disorder diagnosis. The features of NMS in the two groups were very similar, except that people with 2G-NMS were less likely to present with rigidity or extrapyramidal signs compared with those with 1G-NMS. This difference was due to the lower rates of rigidity in those with clozapine-induced NMS. Mortality was considerably lower for those with 2G-NMS (3.0%) compared with 1G-NMS (16.3%), and the former were more likely to have received supportive treatment. CONCLUSIONS The clinical profile of 2G-NMS is largely similar to 1G-NMS, with clozapine-induced NMS being differentiated by the relative lack of rigidity as a feature. Mortality is lower for 2G-NMS.
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Affiliation(s)
- Julian N Trollor
- University of New South Wales, 34 Botany St, Sydney, NSW 2052, Australia.
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Ahuja N, Palanichamy N, Mackin P, Lloyd A. Olanzapine-induced hyperglycaemic coma and neuroleptic malignant syndrome: case report and review of literature. J Psychopharmacol 2010; 24:125-30. [PMID: 18801826 DOI: 10.1177/0269881108096901] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the relationship between antipsychotic medication, particularly second-generation antipsychotics (SGAs), and metabolic disturbance is increasingly accepted, there is an important, but little recognised, potential interaction between this and the other important serious adverse effect of neuroleptic malignant syndrome (NMS). We report a case of a 35-year old female who developed new onset type II diabetes mellitus with hyperosmolar hyperglycaemic coma and acute renal failure following treatment with a SGA for a first manic episode. The history is strongly suggestive of concurrent NMS. This case raises important questions about non-ketotic, hyperosmolar diabetic coma with antipsychotics, the possible association between hyperglycaemia and hyperthermia, and the direction of causality in this, the recognition of either syndrome when they co-exist and management issues in such patients. These questions are considered in the context of currently available literature.
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Affiliation(s)
- N Ahuja
- Wallsend Community Mental Health Team, Sir GB Hunter Hospital, Wallsend, Tyne and Wear, UK.
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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially severe idiosyncratic adverse reaction usually seen in the context of treatment with antipsychotic drugs. Although NMS is historically associated with the classic or 'typical' antipsychotic drugs, it is also a potential adverse effect of atypical antipsychotic drugs. The widespread use of atypical antipsychotic drugs highlights the need to examine the data relating to the symptomatology, diagnosis, classification and management of NMS with these newer agents. We used MEDLINE and EMBASE to identify NMS case reports and systematic reviews published to June 2008 related to the atypical antipsychotic drugs clozapine, olanzapine, risperidone, paliperidone, aripiprazole, ziprasidone, amisulpride and quetiapine. Case reports and reviews were systematically examined. Our review suggests that, in general, NMS associated with atypical antipsychotic drugs manifests in a typical manner. One notable exception is clozapine-induced NMS, which appears less likely to manifest with extrapyramidal features, including rigidity and tremor. The available literature highlights the divergence of opinion relating to the core diagnostic features of NMS and its conceptualization as a categorical versus dimensional disorder. Both these issues have relevance for the identification of atypical or milder forms of NMS, which are sometimes seen with atypical antipsychotic drugs.
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Affiliation(s)
- Julian N Trollor
- School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.
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Neuroleptic malignant syndrome developing after acute overdose with olanzapine and chlorpromazine. J Med Toxicol 2009; 5:27-31. [PMID: 19191213 DOI: 10.1007/bf03160978] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
UNLABELLED Neuroleptic malignant syndrome (NMS) is a relatively uncommon side effect that may develop after a recent increase in the therapeutic dose of an antipsychotic medication or the addition of a new agent in therapeutic doses. CASE REPORT We report a case of NMS developing in a 36-year-old female patient 2 days following deliberate self-poisoning with 30 x 10-mg olanzapine tablets, 7 x 100-mg chlorpromazine tablets and an unknown amount of escitalopram. These were the patient's own medications. She had not been taking these for several weeks. The patient initially presented with sedation from her overdose which resolved over the next 24 hours. Following this, over the subsequent 24 hours, she became progressively confused, ataxic, hypertonic, ferbrile and tachycardic, with marked lead pipe rigidity of the limbs. Head CT, lumbar puncture and septic screen were all negative. She was treated with intravenous midazolam infusion, nasogastrically administered bromocriptine, external cooling and was mechanically ventilated. She gradually improved over a period of 10 days, with residual confusion lasting another week, and was discharged well with no deterioration from her premorbid neurologic state. CONCLUSION To our knowledge, although there are numerous cases reported with therapeutic use, NMS has not been reported to develop following acute olanzapine overdose. Clinicians should be aware that this may be an uncommon side effect of antipsychotic medication.
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Reulbach U, Dütsch C, Biermann T, Sperling W, Thuerauf N, Kornhuber J, Bleich S. Managing an effective treatment for neuroleptic malignant syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 11:R4. [PMID: 17222339 PMCID: PMC2151884 DOI: 10.1186/cc5148] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 12/20/2006] [Accepted: 01/12/2007] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Neuroleptic malignant syndrome (NMS) is a rare, but sometimes fatal, adverse reaction to neuroleptics characterized principally by fever and rigor. The aim of this study was to prove the efficacy of different NMS treatment strategies, focusing on the efficacy of dantrolene. METHODS Altogether, 271 case reports were included. These cases were categorized into four treatment groups and compared to each other according to effectiveness of therapy within 24 hours, mortality, complete time of remission in days, effectiveness due to increase of dosage, relapse on the basis of decrease of dosage, and improvement of symptoms. RESULTS Between the four treatment groups, the complete time of remission was significantly different (analysis of variance, F = 4.02; degrees of freedom = 3; p = 0.008). In a logistic regression with adjustment for age, gender, and severity code, no significant predictor of the treatment for the complete time of remission (dichotomized by median) could be found. However, if the premedication was a monotherapy with neuroleptics, the complete time of remission was significantly shorter with dantrolene monotherapy (t = -2.97; p = 0.004). CONCLUSION The treatment of NMS with drugs that are combined with dantrolene is associated with a prolongation of clinical recovery. Furthermore, treatment of NMS with dantrolene as monotherapy seems to be associated with a higher overall mortality. Therefore, dantrolene does not seem to be the evidence-based treatment of choice in cases of NMS but might be useful if premedication consisted of a neuroleptic monotherapy.
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Affiliation(s)
- Udo Reulbach
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Carmen Dütsch
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Teresa Biermann
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Wolfgang Sperling
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Norbert Thuerauf
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Stefan Bleich
- Department of Psychiatry and Psychotherapy, Friedrich Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany
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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially serious complication of neuroleptic drugs. It may vary in both presenting characteristics and severity. Several different criteria for diagnosis exist, and each differs from the others slightly. We describe a 66-year-old woman with chronic paranoid schizophrenia who was prescribed olanzapine along with several other psychiatric drugs and an antihypertensive drug. The patient displayed several characteristics of NMS during therapy with olanzapine, including fever, elevated creatine kinase level, leukocytosis, and mild muscle rigidity. When olanzapine was held, the signs and symptoms improved and then returned with rechallenge of olanzapine. For this reason, olanzapine was considered strongly associated with this patient's apparent NMS episode. The patient's beta-blocker therapy may have masked additional signs of NMS. In addition, the patient tolerated other neuroleptics that were started in the hospital after the suspected NMS episode. The variation among different diagnostic criteria makes this syndrome a challenging diagnosis at times, in particular when atypical antipsychotics are suspected as the causative agent.
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Affiliation(s)
- Nick B Norgard
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma 73117-5040, USA.
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Abstract
OBJECTIVE Neuroleptic malignant syndrome (NMS) is a rare syndrome with four main symptoms: rigidity, hyperthermia, altered mental status and autonomic instability. We report a patient with an atypical manifestation of NMS. METHOD A single case was reported. RESULTS A patient with pneumonia developed delirium and was treated with olanzapine and developed a NMS with fluctuating hyperthermia and autonomic instability during a month. Only slight rigidity was present. Creatine kinase was not elevated. The patient was severely agitated and manic. After discontinuation of olanzapine the patient showed no psychopathology or hyperthermia. CONCLUSION NMS should be considered when patients treated with antipsychotics develop one or more symptoms of NMS.
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Affiliation(s)
- J Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg, Denmark.
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Bhanushali MJ, Tuite PJ. The evaluation and management of patients with neuroleptic malignant syndrome. Neurol Clin 2004; 22:389-411. [PMID: 15062519 DOI: 10.1016/j.ncl.2003.12.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
NMS is a rare but fatal syndrome that needs to be considered in the perioperative period. Although many aspects remain unexplored and controversial, with greater awareness of the condition, new concepts are coming into light. Definitive treatment guidelines remain an important issue to be addressed. Efforts have been initiated in that direction and all cases can be reported on a toll-free hotline ( 1-888-667-8367) or online (www.nmsis.org).
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Affiliation(s)
- Minal J Bhanushali
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Kontaxakis VP, Havaki-Kontaxaki BJ, Pappa DA, Katritsis DE, Christodoulou GN. Neuroleptic malignant syndrome after addition of paroxetine to olanzapine. J Clin Psychopharmacol 2003; 23:671-2. [PMID: 14624202 DOI: 10.1097/01.jcp.0000096245.29231.a8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kontaxakis VP, Havaki-kontaxaki BJ, Christodoulou NG, Paplos KG, Christodoulou GN. Olanzapine-associated neuroleptic malignant syndrome: Is there an overlap with the serotonin syndrome? ANNALS OF GENERAL HOSPITAL PSYCHIATRY 2003; 2:10. [PMID: 14613516 PMCID: PMC272936 DOI: 10.1186/1475-2832-2-10] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/27/2002] [Accepted: 10/29/2003] [Indexed: 11/13/2022]
Abstract
Background The neuroleptic malignant syndrome is a rare but serious condition mainly associated with antipsychotic medication. There are controversies as to whether "classical" forms of neuroleptic malignant syndrome can occur in patients given atypical antipsychotics. The serotonin syndrome is caused by drug-induced excess of intrasynaptic 5-hydroxytryptamine. The possible relationship between neuroleptic malignant syndrome and serotonin syndrome is at present in the focus of scientific interest. Methods This retrospective phenomenological study aims to examine the seventeen reported olanzapine – induced neuroleptic malignant syndrome cases under the light of possible overlap between neuroleptic malignant syndrome and serotonin syndrome clinical features. Results The serotonin syndrome clinical features most often reported in cases initially diagnosed as neuroleptic malignant syndrome are: fever (82%), mental status changes (82%) and diaphoresis (47%). Three out of the ten classical serotonin syndrome clinical features were concurrently observed in eleven (65%) patients and four clinical features were observed in seven (41%) patients. Conclusion The results of this study show that the clinical symptoms of olanzapine-induced neuroleptic malignant syndrome and serotonin syndrome are overlapping suggesting similarities in underlying pathophysiological mechanisms.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:253-68. [PMID: 12733480 DOI: 10.1002/pds.789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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