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Sadati S, Elyasi F, Shyasi Z, Rouhanizadeh B. Long prodromal symptoms of neuroleptic malignant syndrome in patient with intellectual developmental disorder-A case report. Neuropsychopharmacol Rep 2024. [PMID: 38832410 DOI: 10.1002/npr2.12454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare and potentially life-threatening condition that may arise at any point during treatment and is often associated with adverse reactions to dopamine-blocking agents. This syndrome is normally characterized by features such as muscle rigidity, alteration in consciousness, autonomic instability, and leukocytosis. AIM The aim of this study is to investigate a borderline intellectual functioning (BIF) case in which NMS with insidious disease progression and long prodromal symptoms was developed. CASE PRESENTATION The investigated patient was a 38-year-old female diagnosed with bipolar disorder and a variety of corresponding disorders. The patient exhibited gastrointestinal symptoms and restlessness in the weeks leading up to the study, subsequent to the administration of elevated doses of haloperidol, risperidone, and lithium. In addition, she was hospitalized for restlessness and aggressiveness in the summer of 2023. Furthermore, due to her chief complaint, she received parenteral haloperidol twice in the emergency room, subsequently experiencing fever, altered consciousness, generalized rigidity, and dysphagia. Moreover, the patient's initial creatine phosphokinase (CPK) level was 2550 IU/L, and she was hospitalized in an intensive care unit with the diagnosis of NMS for 8 days. CONCLUSIONS This case study highlights the necessity of being attentive about prodromal symptoms of NMS and emergent interventions.
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Affiliation(s)
- Seyedehnasibeh Sadati
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Forouzan Elyasi
- Faculty of Medicine, Sexual and Reproductive Health Research Center, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zahra Shyasi
- Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Virolle J, Redon M, Montastruc F, Taïb S, Revet A, Zivkovic V, Da Costa J, Very E. What clinical analysis of antipsychotic-induced catatonia and neuroleptic malignant syndrome tells us about the links between these two syndromes: A systematic review. Schizophr Res 2023; 262:184-200. [PMID: 37599139 DOI: 10.1016/j.schres.2023.08.003] [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: 02/18/2023] [Revised: 05/17/2023] [Accepted: 08/05/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVES Antipsychotic-induced catatonia (AIC) and neuroleptic malignant syndrome (NMS) are life-threatening adverse reactions to antipsychotic medication. We conducted a systematic review of literature following the PRISMA statement guidelines to obtain a description of these syndromes (population, context of occurrence, antipsychotic agents implicated) and draw conclusions about their links. METHODS We searched Medline and Web of science databases from January 1951 to May 2019 (further restricted from 2000 to 2019) using search terms including "catatonia", "neuroleptic malignant syndrome" and "antipsychotic agents" for case reports, case series and analytic studies. After screening 4082 records, 410 full-text articles (describing 555 events) were assessed for eligibility. We included events of AIC and/or NMS according to Diagnostic and Statistical Manual (DSM) criteria and extracted data about patients' characteristics, context of occurrence, antipsychotic agent(s) involved and treatment outcomes. RESULTS We included 165 events (16 AIC, 129 NMS and 20 AIC + NMS) from 144 case reports and case series. The most reported diagnosis was schizophrenia. Comorbid pre-existing conditions such as central nervous system diseases and acute medical events were common. Most of the events (63.3 %) occurred during antipsychotic monotherapy. Second-generation antipsychotics (SGAs, 63.8 %) were overall more implicated than first-generation antipsychotics (FGAs, 36.2 %). DISCUSSION Our findings highlight that any antipsychotic medication, even SGA monotherapy prescribed at recommended dose, is at risk for these side effects. FGAs and polypharmacy seem to represent risk factors for malignant catatonia in AIC. The clinical overlap observed between AIC and NMS events in our review suggests a clinical continuum between catatonia and NMS.
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Affiliation(s)
- Jordan Virolle
- Department of Psychiatry, Psychotherapy, and Art Therapy, Toulouse University Hospital (CHU Toulouse), Toulouse, France.
| | - Maximilien Redon
- Department of Psychiatry, Psychotherapy, and Art Therapy, Toulouse University Hospital (CHU Toulouse), Toulouse, France.
| | - François Montastruc
- CIC 1436, Team PEPSS « Pharmacologie En Population cohorteS et biobanqueS », Toulouse University Hospital, Toulouse, France; Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Toulouse University Hospital, Faculty of Medicine, Toulouse, France.
| | - Simon Taïb
- Department of Psychiatry, Psychotherapy, and Art Therapy, Toulouse University Hospital (CHU Toulouse), Toulouse, France; ToNIC, Toulouse NeuroImaging Center, Inserm UMR 1214, Toulouse III - Paul Sabatier University, Toulouse, France.
| | - Alexis Revet
- Department of Child and Adolescent Psychiatry, Toulouse University Hospital (CHU Toulouse), Toulouse, France; CERPOP, UMR 1295, Inserm, Toulouse III - Paul Sabatier University, Toulouse, France.
| | - Vuk Zivkovic
- Department of Psychiatry, Psychotherapy, and Art Therapy, Toulouse University Hospital (CHU Toulouse), Toulouse, France.
| | - Julien Da Costa
- Pôle de Psychiatrie et Conduites Addictives en Milieu Pénitentiaire, Gérard Marchant Psychiatric Hospital, Toulouse, France.
| | - Etienne Very
- Department of Psychiatry, Psychotherapy, and Art Therapy, Toulouse University Hospital (CHU Toulouse), Toulouse, France; ToNIC, Toulouse NeuroImaging Center, Inserm UMR 1214, Toulouse III - Paul Sabatier University, Toulouse, France.
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Im DS, Capitanov M, VandenBerg AM. Loxapine in the Treatment of Manic and Psychotic Symptoms in an Individual Intolerant to Multiple Mood-Stabilizing and Antipsychotic Medications. Case Rep Psychiatry 2023; 2023:8887553. [PMID: 37332889 PMCID: PMC10276762 DOI: 10.1155/2023/8887553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 06/20/2023] Open
Abstract
First-line treatments for schizophrenia and schizoaffective disorder include antipsychotics and mood stabilizers, but their use may at times be limited due to severe adverse events. This case describes a 41-year-old male with a history of schizoaffective disorder and polysubstance use who was admitted to an inpatient psychiatry unit for acute manic and psychotic symptoms in the setting of absconding from his residential home and noncompliance with prescribed psychiatric medications. During his inpatient psychiatric hospitalization, he experienced DRESS (drug reaction with eosinophilia and systemic symptoms) with valproate, nephrogenic diabetes insipidus with lithium, potential neuroleptic malignant syndrome with risperidone, and orthostasis/tachycardia with clozapine. He ultimately achieved stabilization of manic and psychotic symptoms with loxapine without experiencing adverse events. This report highlights the potential utility of loxapine in individuals with schizoaffective disorder intolerant to standard mood-stabilizing and antipsychotic medications.
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Affiliation(s)
- David S. Im
- Department of Psychiatry, University of Michigan Medical School, USA
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Yoshida K, Takeuchi H. Dose-dependent effects of antipsychotics on efficacy and adverse effects in schizophrenia. Behav Brain Res 2021; 402:113098. [PMID: 33417992 DOI: 10.1016/j.bbr.2020.113098] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/02/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antipsychotics are a cornerstone of pharmacological treatment of schizophrenia. Improved understanding of the dose-response relationship of antipsychotics in terms of efficacy, adverse effects, and mortality can help to optimize the pharmacological treatment of schizophrenia. METHODS This narrative literature review summarizes current evidence on the relationship of antipsychotic dose with efficacy, adverse effects, and mortality in patients with schizophrenia. RESULTS The efficacy of antipsychotics generally appeared to be highly dose-dependent in the acute phase of schizophrenia, with each antipsychotic having a specific dose-response curve. The presence or absence of dose-dependency and its extent varied according to the type of adverse effect. Parkinsonism, hyperprolactinemia, weight gain, and neurocognitive impairment appeared to be dose-related. The following adverse effects might be at least somewhat dose-dependent: akathisia, tardive dyskinesia, osteoporosis, sexual dysfunction, diabetes mellitus, myocardial infarction, stroke, thromboembolism, QT interval prolongation, anticholinergic adverse effects, somnolence, pneumonia, hip fracture, and neuroleptic malignant syndrome. In contrast, the relationships of antipsychotic dose with dyslipidemia, hypotension, seizure, sialorrhea, and neutropenia and agranulocytosis remained unclear due to mixed findings and/or limited data. Although a higher lifetime cumulative antipsychotic dose might contribute to higher mortality, it is still difficult to conclude whether mortality increases in a dose-dependent manner. CONCLUSION These findings could help clinicians to optimize antipsychotic treatment in patients with schizophrenia by balancing risks and benefits in clinical practice. However, further investigations with larger sample sizes and more robust study designs that focus on each antipsychotic agent are needed.
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Affiliation(s)
- Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Lao KSJ, Zhao J, Blais JE, Lam L, Wong ICK, Besag FMC, Chang WC, Castle DJ, Chan EW. Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study. CNS Drugs 2020; 34:1165-1175. [PMID: 33010024 DOI: 10.1007/s40263-020-00767-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available. OBJECTIVES The aim of this study was to ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS. METHODS We did a population-based study using data from the Hong Kong Hospital Authority's Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91-120 days before the index date. To adjust for potential time trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications and acute medical conditions. RESULTS 297,647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time trend, and case-crossover adjusted for time trend and potential confounders analysis were 8.00 (95% confidence interval 3.42-18.69), 5.88 (2.46-14.04), and 4.77 (1.95-11.66). CONCLUSIONS Our results suggest that recent use of antipsychotics is associated with NMS. Although a case-only design inherently controls for confounding by time-invariant factors, residual confounding by acute medical conditions with similar presentations to NMS cannot be fully excluded.
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Affiliation(s)
- Kim S J Lao
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.,Global Medical Affairs, Merck Research Laboratories, Shanghai, China
| | - Jiaxi Zhao
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Joseph Edgar Blais
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Lam Lam
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.,Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Frank M C Besag
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.,East London NHS Foundation Trust, Bedford, Bedfordshire, UK.,Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Wing Chung Chang
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Brain & Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - David J Castle
- St Vincent's Hospital, Melbourne, Vic, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Vic, Australia
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China. .,Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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Kalelioglu T, Karamustafalioglu N, Celikel G, Genc A, Emul M. Serum osmolarity and blood viscosity as a potential explanation for the pathophysiology of neuroleptic malignant syndrome. Int J Psychiatry Clin Pract 2019; 23:307-310. [PMID: 31116616 DOI: 10.1080/13651501.2019.1617884] [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: 10/26/2022]
Abstract
Background: Neuroleptic malignant syndrome (NMS) is a rare but life-threatening side effect. NMS patients usually develop dehydration and fluid-electrolyte imbalance. In this study, we aimed to investigate serum osmolarity and blood viscosity in patients with NMS.Methods: This was a retrospective case-control study including 32 admissions of 27 patients with the diagnosis of NMS. As a control group, 31 non-NMS episodes of hospitalizations of the same patients were included.Results: Serum osmolarity of NMS group was 301.83 ± 20.27 mOsm/L and control group was 294.20 ± 5.92 mOsm/L. Serum osmolarity of NMS group was statistically significantly higher than the controls (p = .018). Whole blood viscosity (WBV) at high shear rate (HSR) value of NMS group was 16.17 ± 1.48 and control group was 16.50 ± 1.38 (p = .331). Regarding WBV at low shear rate (LSR) values, also no statistically significant difference was observed between groups. LSR values of NMS and control group were 39.86 ± 30.11 and 47.41 ± 28.43, respectively (p = .387).Conclusions: Our findings indicate that serum osmolarity of NMS group was statistically significantly higher than the controls. In terms of blood viscosity, there was no statistically significant difference between groups. Higher serum osmolarity in NMS patients than controls may be a reflection of a relative hemoconcentration in NMS.KEY POINTSNMS is usually associated with dehydration resulting in fluid-electrolyte imbalance.We compared the NMS episodes with non-NMS hospitalizations (as control group) of the same patients.Serum osmolarity was statistically significantly higher in NMS group than the controls.There was no statistically significant difference between groups in terms of blood viscosity.
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Affiliation(s)
- Tevfik Kalelioglu
- Department of Psychiatry, Bakırköy Mental Health Research and Training State Hospital, Istanbul, Turkey
| | - Nesrin Karamustafalioglu
- Department of Psychiatry, Bakırköy Mental Health Research and Training State Hospital, Istanbul, Turkey
| | - Guler Celikel
- Department of Psychiatry, Bakırköy Mental Health Research and Training State Hospital, Istanbul, Turkey
| | - Abdullah Genc
- Department of Psychiatry, Şişli Hamidiye Etfal Research and Training State Hospital, Istanbul, Turkey
| | - Murat Emul
- Private Psychiatry Practice, Istanbul, Turkey
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Korchia T, Blackman G, Cermolacce M, Richieri R. Neuroleptic malignant syndrome following reintroduction of an antipsychotic after overdose. BMJ Case Rep 2018; 2018:bcr-2017-223922. [PMID: 30076161 PMCID: PMC6078231 DOI: 10.1136/bcr-2017-223922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse drug reaction. We report a case of NMS potentially induced by dehydration in a female patient suffering from schizoaffective disorder. We discuss possible aetiologies and triggering factors alongside the existing literature.
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Affiliation(s)
- Théo Korchia
- Department of Psychiatry, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Michel Cermolacce
- Department of Psychiatry, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Raphaëlle Richieri
- Department of Psychiatry, Assistance Publique Hopitaux de Marseille, Marseille, France
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Institut Fresnel - UMR 7249, Faculté des Sciences de Saint Jérôme, Marseille, France
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8
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Khan GS, Raza M, Hussain N. A Forme Fruste Presentation of Neuroleptic Malignant Syndrome Caused by Antipsychotic Medication. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180406-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tormoehlen LM, Rusyniak DE. Neuroleptic malignant syndrome and serotonin syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2018; 157:663-675. [PMID: 30459031 DOI: 10.1016/b978-0-444-64074-1.00039-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The clinical manifestation of drug-induced abnormalities in thermoregulation occurs across a variety of drug mechanisms. The aim of this chapter is to review two of the most common drug-induced hyperthermic states, serotonin syndrome and neuroleptic malignant syndrome. Clinical features, pathophysiology, and treatment strategies will be discussed, in addition to differentiating between these two syndromes and differentiating them from other hyperthermic or febrile syndromes. Our goal is to both review the current literature and to provide a practical guide to identification and treatment of these potentially life-threatening illnesses. The diagnostic and treatment recommendations made by us, and by other authors, are likely to change with a better understanding of the pathophysiology of these syndromes.
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Affiliation(s)
- Laura M Tormoehlen
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, United States; Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Daniel E Rusyniak
- Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States.
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Sheehan R, Horsfall L, Strydom A, Osborn D, Walters K, Hassiotis A. Movement side effects of antipsychotic drugs in adults with and without intellectual disability: UK population-based cohort study. BMJ Open 2017; 7:e017406. [PMID: 28775195 PMCID: PMC5724123 DOI: 10.1136/bmjopen-2017-017406] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To measure the incidence of movement side effects of antipsychotic drugs in adults with intellectual disability and compare rates with adults without intellectual disability. DESIGN Cohort study using data from The Health Improvement Network. SETTING UK primary care. PARTICIPANTS Adults with intellectual disability prescribed antipsychotic drugs matched to a control group of adults without intellectual disability prescribed antipsychotic drugs. OUTCOME MEASURES New records of movement side effect including acute dystonias, akathisia, parkinsonism, tardive dyskinaesia and neuroleptic malignant syndrome. RESULTS 9013 adults with intellectual disability and a control cohort of 34 242 adults without intellectual disability together contributed 148 709 person-years data. The overall incidence of recorded movement side effects was 275 per 10 000 person-years (95% CI 256 to 296) in the intellectual disability group and 248 per 10 000 person-years (95% CI 237 to 260) in the control group. The incidence of any recorded movement side effect was significantly greater in people with intellectual disability compared with those without (incidence rate ratio 1.30, 95% CI 1.18 to 1.42, p<0.001, after adjustment for potential confounders), with parkinsonism and akathisia showing the greatest difference between the groups. Neuroleptic malignant syndrome, although occurring infrequently, was three times more common in people with intellectual disability-prescribed antipsychotic drugs (incidence rate ratio 3.03, 95% CI 1.26 to 7.30, p=0.013). Differences in rates of movement side effects between the groups were not due to differences in the proportions prescribed first and second-generation antipsychotic drugs. CONCLUSIONS This study provides evidence to substantiate the long-held assumption that people with intellectual disability are more susceptible to movement side effects of antipsychotic drugs. Assessment for movement side effects should be integral to antipsychotic drug monitoring in people with intellectual disability. Regular medication review is essential to ensure optimal prescribing in this group.
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Affiliation(s)
- Rory Sheehan
- Division of Psychiatry, University College London, London, UK
| | - Laura Horsfall
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - André Strydom
- Division of Psychiatry, University College London, London, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
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Gurrera RJ. A systematic review of sex and age factors in neuroleptic malignant syndrome diagnosis frequency. Acta Psychiatr Scand 2017; 135:398-408. [PMID: 28144982 DOI: 10.1111/acps.12694] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To examine sex and age distributions in neuroleptic malignant syndrome (NMS) patients based on a systematic literature review. METHOD EMBASE and PubMed databases were searched to identify any observation of NMS published from January 1, 1998 through November 1, 2014 that was accessible and interpretable (using language translation software). Redundant and equivocal reports were excluded. Sex ratio and age distributions were examined using standard graphical techniques and measures of association. RESULTS Twenty-eight independent sex ratio estimates were included. Males predominated in most (75%) estimates with an overall median sex ratio of 1.47 (95% CI, 1.20-1.80). NMS incidence peaked at age 20-25 years and declined steadily thereafter, with males consistently outnumbering females at all but the oldest age intervals. CONCLUSION NMS patients are 50% more likely to be males, and NMS is most likely to occur in young adulthood.
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Affiliation(s)
- Ronald J Gurrera
- Veteran Affairs Boston Healthcare System, Boston MA and Harvard Medical School Department of Psychiatry, Boston, MA, USA
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12
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Abstract
Up to 90% of patients on chronic antipsychotic therapy will experience adverse neurologic side effects, with many of these effects attributable to the dopamine-blocking properties of these drugs. Even the newer, “atypical” antipsychotics are increasingly associated with neurologic complications. In the acute care setting, these medications have broad application beyond the management of psychiatric illness. Given the extent of their use, clinicians should be familiar with the spectrum of neurological syndromes that can develop. Some are common, such as akathisia, acute dystonic reaction, tardive dyskinesia, and drug-induced parkinsonism. Others, such as the life-threatening neuroleptic malignant syndrome, are rare yet must be recognized early to affect survival and improve outcome. This discussion highlights 2 idiosyncratic syndromes, acute dystonic reaction and neuroleptic malignant syndrome. The differential diagnosis for both syndromes and their management is discussed.
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Affiliation(s)
- Suzanne R. White
- Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine, Children’s Hospital of Michigan Regional Poison Control Center, Detroit, Michigan,
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Tseng PT, Chang YC, Chang CH, Wang HY, Cheng YS, Wu CK, Chen YW, Chung W. Atypical neuroleptic malignant syndrome in patients treated with aripiprazole and clozapine: a case-series study and short review. Int J Psychiatry Med 2015; 49:35-43. [PMID: 25838319 DOI: 10.2190/pm.49.1.c] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Neuroleptic malignant syndrome (NMS) requires emergency treatment and can be fatal. Combined aripiprazole and clozapine therapy is rarely used in clinical settings, and NMS related this combination still lacks evaluation. Herein, we present two cases of atypical NMS treated with aripiprazole and clozapine. METHODS Case 1 was a schizophrenic male with a history of NMS under treatment with aripiprazole 20 mg. He was hospitalized and maintained with aripiprazole 5 mg and clozapine 225 mg. On the 25th day, atypical NMS occurred with rigidity, elevated creatine kinase, and stupor, which subsided with supportive therapy. He was discharged under treatment with aripiprazole 15 mg and fluoxetine 60 mg. Case 2 was a female with schizoaffective disorder without a history of NMS. She was hospitalized and maintained with clozapine 50 mg and aripirazole 30 mg. On the 11th day, atypical NMS occurred with mild fever, delirium, and rigidity, which subsided under supportive therapy. RESULTS AND CONCLUSIONS Our cases highlight the atypical features of NMS in patients being treated with combined ari-piprazole and clozapine. Consciousness change, modest elevation of creatine kinase, and leukocytosis were the most consistent findings; hyperthermia accounts for only some of the cases. This is a reminder of the importance of earlier detection of the soft signs and atypical features of NMS under this combined treatment.
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Affiliation(s)
- Ping-Tao Tseng
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Yi-Chung Chang
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Chih-Hua Chang
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Hung-Yu Wang
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Yu-Shian Cheng
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | - Ching-Kuan Wu
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
| | | | - Weilun Chung
- Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan
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Tse L, Barr AM, Scarapicchia V, Vila-Rodriguez F. Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Perspective. Curr Neuropharmacol 2015; 13:395-406. [PMID: 26411967 PMCID: PMC4812801 DOI: 10.2174/1570159x13999150424113345] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/19/2014] [Accepted: 01/11/2015] [Indexed: 11/22/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side-effect that can occur in response to treatment with antipsychotic drugs. Symptoms commonly include hyperpyrexia, muscle rigidity, autonomic dysfunction and altered mental status. In the current review we provide an overview on past and current developments in understanding the causes and treatment of NMS. Studies on the epidemiological incidence of NMS are evaluated, and we provide new data from the Canada Vigilance Adverse Reaction Online database to elaborate on drug-specific and antipsychotic drug polypharmacy instances of NMS reported between 1965 and 2012. Established risk factors are summarized with an emphasis on pharmacological and environmental causes. Leading theories about the etiopathology of NMS are discussed, including the potential contribution of the impact of dopamine receptor blockade and musculoskeletal fiber toxicity. A clinical perspective is provided whereby the clinical presentation and phenomenology of NMS is detailed, while the diagnosis of NMS and its differential is expounded. Current therapeutic strategies are outlined and the role for both pharmacological and non-pharmacological treatment strategies in alleviating the symptoms of NMS are discussed.
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Affiliation(s)
| | | | | | - Fidel Vila-Rodriguez
- Non-Invasive Neurostimulation Therapies Laboratory at UBC (NINET), UBC Hospital; Detwiller Pavilion, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1.
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Guru S, Vanamoorthy U, Loganathan S, Varghese M. Neuroleptic malignant syndrome following abrupt anti-cholinergic withdrawal: a case report. Asian J Psychiatr 2014; 12:158-9. [PMID: 25440569 DOI: 10.1016/j.ajp.2014.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 04/14/2014] [Accepted: 05/25/2014] [Indexed: 11/27/2022]
Affiliation(s)
- S Guru
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India.
| | - Umamaheswari Vanamoorthy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Santosh Loganathan
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
| | - Mathew Varghese
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India
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Su YP, Chang CK, Hayes RD, Harrison S, Lee W, Broadbent M, Taylor D, Stewart R. Retrospective chart review on exposure to psychotropic medications associated with neuroleptic malignant syndrome. Acta Psychiatr Scand 2014; 130:52-60. [PMID: 24237642 DOI: 10.1111/acps.12222] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the association between neuroleptic malignant syndrome (NMS) and levels of antipsychotic exposure. METHOD Electronic health record data systematically screened from a large mental health service provider in southeast London provided 67 NMS cases which were individually matched with 254 controls on age, gender, and primary psychiatric diagnosis. Data on psychotropic agents, combinations, dose, and dose change of antipsychotic prescriptions over the preceding 5 (oral agents) or 15 days (depot agents) were extracted and compared between groups using conditional logistic regression models. RESULTS NMS was associated with higher number of antipsychotic agents used, use of first-generation agents or aripiprazole, use of first-generation agents only or cross-generation agents, and higher mean and maximum daily doses. In further analyses, associations with antipsychotics type remained significant when adjusted for dose, but those with dose were attenuated following adjustment for type. The specific use of haloperidol, aripiprazole, depot flupentixol, and benzodiazepines was independently associated with NMS. Non-white ethnicity was also found to be associated with NMS. CONCLUSION NMS was primarily associated with type of antipsychotic and polypharmacy rather than overall dose. Variation in risk by ethnicity requires further research.
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Affiliation(s)
- Y-P Su
- King's College London, Institute of Psychiatry, London, UK; Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan; School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
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Detweiler MB, Sullivan K, Sharma TR, Kim KY, Detweiler JG. Case reports of neuroleptic malignant syndrome in context of quetiapine use. Psychiatr Q 2013; 84:523-41. [PMID: 23686527 DOI: 10.1007/s11126-013-9264-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A retrospective analysis was followed on 20 case reports covering the possible correlation between the atypical antipsychotic, quetiapine, and neuroleptic malignant syndrome (NMS), determined by the study of 7 different NMS criteria guidelines. A great majority (19) of the case studies did not meet the requirements of all 7 guidelines, frequently due to unreported information. Nor was quetiapine proven to be the sole cause of the possible NMS in the two age groups investigated. Only one case was found to have no other medication or medical conditions confounding the relationship of quetiapine and NMS symptoms, and that case was in the context of a significant quetiapine overdose. The other 19 cases demonstrated the difficulty of identifying the cause of NMS when polypharmacy and other medical conditions are involved. The authors note the need for caution in deciding both the presence of NMS and the causal factors of the symptoms.
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Affiliation(s)
- Mark B Detweiler
- Psychiatry Service, Veterans Affairs Medical Center, 1970 Roanoke Boulevard (116A7), Salem, VA, 24153, USA,
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18
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Kwack YS, Ryu JS. Neuroleptic Malignant Syndrome in Children and Adolescents : A Review. Soa Chongsonyon Chongsin Uihak 2013. [DOI: 10.5765/jkacap.2013.24.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Woods G, Taggart C, Boggs R, Cadden I. Neuroleptic malignant syndrome associated with quetiapine and venlafaxine use: a case report and discussion. Ther Adv Psychopharmacol 2013; 3:53-5. [PMID: 23983992 PMCID: PMC3736958 DOI: 10.1177/2045125312464386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gary Woods
- Ards Community Hospital, South Eastern Health and Social Care Trust, Newtownards, UK
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Langan J, Martin D, Shajahan P, Smith DJ. Antipsychotic dose escalation as a trigger for neuroleptic malignant syndrome (NMS): literature review and case series report. BMC Psychiatry 2012; 12:214. [PMID: 23194104 PMCID: PMC3546951 DOI: 10.1186/1471-244x-12-214] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 11/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND "Neuroleptic malignant syndrome" (NMS) is a potentially fatal idiosyncratic reaction to any medication which affects the central dopaminergic system. Between 0.5% and 1% of patients exposed to antipsychotics develop the condition. Mortality rates may be as high as 55% and many risk factors have been reported. Although rapid escalation of antipsychotic dose is thought to be an important risk factor, to date it has not been the focus of a published case series or scientifically defined. DESCRIPTION We aimed to identify cases of NMS and review risk factors for its development with a particular focus on rapid dose escalation in the 30 days prior to onset. A review of the literature on rapid dose escalation was undertaken and a pragmatic definition of "rapid dose escalation" was made. NMS cases were defined using DSM-IV criteria and systematically identified within a secondary care mental health service. A ratio of titration rate was calculated for each NMS patient and "rapid escalators" and "non rapid escalators" were compared. 13 cases of NMS were identified. A progressive mean dose increase 15 days prior to the confirmed episode of NMS was observed (241.7 mg/day during days 1-15 to 346.9 mg/day during days 16-30) and the mean ratio of dose escalation for NMS patients was 1.4. Rapid dose escalation was seen in 5/13 cases and non rapid escalators had markedly higher daily cumulative antipsychotic dose compared to rapid escalators. CONCLUSIONS Rapid dose escalation occurred in less than half of this case series (n = 5, 38.5%), although there is currently no consensus on the precise definition of rapid dose escalation. Cumulative antipsychotic dose - alongside other known risk factors - may also be important in the development of NMS.
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Affiliation(s)
- Julie Langan
- Institute of Health an Wellbeing, Mental Health and Wellbeing, Gartnavel Royal Hospital, University of Glasgow, 1055 Great Western Road, Glasgow, G12 0XH, Scotland, UK
| | - Daniel Martin
- Institute of Health an Wellbeing, Mental Health and Wellbeing, Gartnavel Royal Hospital, University of Glasgow, 1055 Great Western Road, Glasgow, G12 0XH, Scotland, UK
| | - Polash Shajahan
- NHS Lanarkshire, Greenmoss Community Health centre, University of Glasgow, Greenmoss Place, Bellshill, ML4 1PS, Scotland, UK
| | - Daniel J Smith
- Institute of Health an Wellbeing, Mental Health and Wellbeing, Gartnavel Royal Hospital, University of Glasgow, 1055 Great Western Road, Glasgow, G12 0XH, Scotland, UK
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Abstract
OBJECTIVES To review the diagnosis and management of four selected psychiatric emergencies in the intensive care unit: agitated delirium, neuroleptic malignant syndrome, serotonin syndrome, and psychiatric medication overdose. DATA SOURCES Review of relevant medical literature. DATA SYNTHESIS Standardized screening for delirium should be routine. Agitated delirium should be managed with an antipsychotic and, possibly, dexmedetomidine in treatment-refractory cases. Delirium management should also include ensuring a calming environment and adequate pain control, minimizing benzodiazepines and anticholinergics, normalizing the sleep-wake cycle, providing sensory aids as required, and providing early physical and occupational therapy. Neuroleptic malignant syndrome should be treated by discontinuing dopamine blockers, providing supportive therapy, and possibly administering medications (benzodiazepines, dopamine agonists, and/or dantrolene) or electroconvulsive therapy, if indicated. Serotonin syndrome should be treated by discontinuing all serotonergic agents, providing supportive therapy, controlling agitation with benzodiazepines, and possibly administering serotonin2A antagonists. It is often unnecessary to restart psychiatric medications upon which a patient has overdosed in the intensive care unit, though withdrawal syndromes should be prevented, and communication with outpatient prescribers is vital. CONCLUSIONS Understanding the diagnosis and appropriate management of these four psychiatric emergencies is important to provide safe and effective care in the intensive care unit.
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Nielsen RE, Wallenstein Jensen SO, Nielsen J. Neuroleptic malignant syndrome-an 11-year longitudinal case-control study. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:512-8. [PMID: 22854034 DOI: 10.1177/070674371205700810] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe patients with neuroleptic malignant syndrome (NMS), to establish occurrence of NMS, to investigate risk factors of NMS, and to investigate mortality associated with NMS. METHOD We conducted a longitudinal register linkage case-control study of NMS. RESULT In health care registers covering the period from 1996 to 2007, we identified, among 224 372 patients with organic, psychotic, affective, or neurotic diagnosis, 83 patients with NMS, equivalent to an occurrence of 0.04%. Treatment with second-generation antipsychotics (SGAs) in the 3 months preceding admission increased the NMS risk (OR 4.66; 95% CI 1.96 to 11.10) and also first-generation antipsychotics (FGAs) of high potency (OR 23.41; 95% CI 5.29 to 103.61) and mid potency (OR 4.81; 95% CI 1.96 to 11.79), and depot antipsychotics (OR 4.53; 95% CI 1.60 to 12.80). Benzodiazepines (BDZs) also increased the risk of NMS (OR 3.43; 95% CI 1.68 to 12.80). NMS was associated with an increased mortality (HR 1.88; 95% CI 1.19 to 2.98) in patients, compared with sex-, age-, and diagnosis-matched control subjects, but no significant difference in mortality between patients and control subjects was observed after the initial 30 days (P = 0.27). CONCLUSIONS The occurrence of NMS is low, and the prediction of NMS is difficult. Previous treatment with FGAs, SGAs, and BDZs was identified as a risk factor for developing NMS. NMS increased mortality within 30 days after NMS.
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Affiliation(s)
- René Ernst Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Aalborg, Denmark.
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Margetić B, Aukst-Margetić B. Neuroleptic malignant syndrome and its controversies. Pharmacoepidemiol Drug Saf 2010; 19:429-35. [PMID: 20306454 DOI: 10.1002/pds.1937] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Neuroleptic malignant syndrome (NMS) is a rare and life threatening condition usually defined as a complication of treatment with antipsychotics characterized by severe rigidity, tremor, fever, altered mental status, autonomic dysfunction, and elevated serum creatine phosphokinase and white blood cell count. The literature on this topic is rather extensive, but many aspects related to the syndrome are thought to be controversial. The aim of this paper, written with the clinician in mind, is to summarize some of the most prominent controversies that may have importance in usual clinical practice. METHODS The literature was searched for reviews, reports on the series of cases, individual case reports of NMS, and other clinically and theoretically important information. RESULTS There are controversies associated with virtually all important aspects of NMS. At the moment, it is not clear if this drug reaction is idiosyncratic or not, what diagnostic criteria are the most appropriate for usual clinical practice, and it seems that the estimated incidence is not in accordance with the number of treated patients. There are rather different approaches to the pathophysiological mechanisms, differential diagnosis, and treatment. CONCLUSIONS Some of the controversies related to NMS have an influence on our understanding of the condition and may have importance in clinical practice. There is a need for further research that should elucidate these controversies.
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Chen Y, Guo JJ, Steinbuch M, Buckley PF, Patel NC. Risk of neuroleptic malignant syndrome in patients with bipolar disorder: a retrospective, population-based case-control study. Int J Psychiatry Med 2010; 39:439-50. [PMID: 20391864 DOI: 10.2190/pm.39.4.h] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Current data regarding risk factors of neuroleptic malignant syndrome (NMS) are limited. This study aims to examine factors associated with increased risk of NMS in patients with bipolar disorder. METHODS A retrospective, population-based, case-control study was performed using a medical claims database covering January 1998 to December 2002. Fifty cases with a diagnosis of NMS were identified and matched with 800 controls. Conditional logistic regression analysis was used to estimate crude and adjusted odds ratios (ORs) of risk of NMS. RESULTS Antipsychotic use was associated with an increased risk of NMS after controlling for other pharmacologic and clinical factors (OR = 2.36, 95% CI = 1.08-5.19). Other factors associated with an increased risk of NMS included being male (OR = 2.07, 95% CI = 1.07-4.02), confusion (OR = 2.91, 95% CI = 1.17-7.28), dehydration (OR = 3.99, 95% CI = 1.50-10.57), delirium (OR = 4.93, 95% CI = 2.07-11.72), and extrapyramidal symptoms (OR = 3.50, 95% CI = 1.10-11.09). CONCLUSIONS Given the widespread use of antipsychotics for the treatment of bipolar disorder, clinicians should be vigilant of the potential pharmacologic and clinical factors associated with increased risk of NMS in patients with bipolar disorder.
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Affiliation(s)
- Yan Chen
- Department of Pharmacy Practice and Administrative Sciences, School of Pharmacy, University of Cincinnati Medical Center, Ohio 45267-0004, USA.
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Tural U, Onder E. Clinical and pharmacologic risk factors for neuroleptic malignant syndrome and their association with death. Psychiatry Clin Neurosci 2010; 64:79-87. [PMID: 20416027 DOI: 10.1111/j.1440-1819.2009.02042.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The aim of the present study was to evaluate demographics, clinical features, psychiatric diagnoses and prognosis of neuroleptic malignant syndrome (NMS) reported in Turkey, and to assess their association with mortality. METHODS Data on all reported cases of NMS in the Turkish Psychiatric Index between 1985 and 2005 were collected. The type, dosage and administration period of neuroleptics, the clinical and laboratory findings; and prognosis were compared in terms of mortality. RESULTS Thirty-six patients with a mean age of 33.67 +/- 16.98 years were identified. Fifteen (41.7%) were diagnosed as having schizophrenia or other psychotic disorders and the same number were diagnosed as having affective disorder. Remaining five (13.9%) were diagnosed with other psychiatric disorders and 1 (2.7%) had no psychiatric diagnosis. Twenty-two (61.1%) of the NMS cases were associated with high potency typical neuroleptics. Association between an atypical antipsychotic and NMS has been reported in one case. NMS appeared within 7 days after initiation of the antipsychotic medication in the majority of samples (n = 19, 52.8%). Several combinations of rescue treatments were used in the majority of cases (n = 19, 52.8%), although bromocriptine (n = 22, 61.1%) was the most frequently preferred rescue treatment for NMS. Benzodiazepines were significantly better than the other treatment options in preventing mortality. Five out of the 36 patients (13.9%) with NMS had died. Age was the only significant independent factor that was associated with mortality. CONCLUSIONS Benzodiazepines may be included in the treatment of NMS. The mortality rate due to NMS in Turkey was lower than the previously reported rates from other developing countries.
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Affiliation(s)
- Umit Tural
- Department of Psychiatry, Medical Faculty, Kocaeli University, Kocaeli, Turkey.
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Reversible splenial lesion syndrome in neuroleptic malignant syndrome. Biomed Imaging Interv J 2009; 5:e24. [PMID: 21610992 PMCID: PMC3097717 DOI: 10.2349/biij.5.4.e24] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 05/03/2009] [Accepted: 07/15/2009] [Indexed: 11/17/2022] Open
Abstract
Background Reversible focal lesions in the splenium of the corpus callosum (SCC) or reversible splenial lesion syndrome are rare and little is known about their pathophysiology. Case summary The authors describe a case of a 65-year-old female who presented with fever, abnormal behaviour and mild hypernatremia. She was on neuropsychiatric treatment for bipolar disorder but denied any history of seizure. After an extensive workout to exclude infection, a clinical diagnosis of neuroleptic malignant syndrome (NMS) was made. Initial magnetic resonance imaging (MRI) of the brain showed a lesion in the SCC characterized by high-signal intensity on T2-weighted and FLAIR sequences with reduced signal intensity on T1-weighted sequence. Diffuse weighted imaging (DWI) showed restricted diffusion. There was no enhancement following Gadolinium administration. The follow-up MRI 8 weeks later showed complete resolution of the SCC lesion. Conclusion While the pathophysiology of reversible SCC lesions is still unclear, this case highlights the need to consider NMS in the differential diagnosis of reversible splenial lesion of the corpus callosum.
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Sanai T, Matsui R, Hirano T, Torichigai S, Yotsueda H, Higashi H, Hirakata H, Iida M. Successful Treatment of Six Patients with Neuroleptic Malignant Syndrome Associated with Myoglobulinemic Acute Renal Failure. Ren Fail 2009; 28:51-5. [PMID: 16526319 DOI: 10.1080/08860220500461252] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Neuroleptic malignant syndrome is a rare but potentially lethal, rare reaction to neuroleptics which is characterized by altered levels of consciousness, extrapyramidal effects, autonomic instability, hyperthermia, and elevated serum creatine phosphokinase levels. The most serious complication of neuroleptic malignant syndrome is acute renal failure. We investigated six cases of neuroleptic malignant syndrome associated with myoglobulinemic acute renal failure due to rhabdomyolysis and effect of hemodialysis or hemodiafiltration. The patients were five males and one female with a mean age of 43.5 yr. All of the patients, who developed acute renal failure induced from rhabdomyolysis, had previously received butyrophenone (haloperidol), phenothiazine, benzamide, iminomide, benzisoxazole, antidepressants, and hypnotics (benzodiazepine and barbiturate) for the treatment of schizophrenia. The clinical manifestations of neuroleptic malignant syndrome were characterized by altered consciousness, muscle rigidity and weakness, fever, and excessive perspiration. The peak laboratory data were blood urea nitrogen 102 +/- 26 (mean +/- SD) mg/dL, serum creatinine 9.1 +/- 2.1 mg/dL, serum creatine phosphokinase 229,720 +/- 289,940 IU/L, and all of them developed oliguric acute renal failure. Dantrolene sodium administration was given to five cases and hemodialysis or hemodiafiltration was performed in all of them. The serum creatinine level after hemodialysis or hemodiafiltration was 1.4 +/- 1.0 mg/dL. All patients were successfully cured of acute renal failure by hemodialysis or hemodiafiltration. As a result, myoglobulinemic acute renal failure associated with neuroleptic malignant syndrome was successfully treated by hemodialysis or hemodiafiltration.
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Affiliation(s)
- Toru Sanai
- The Division of Nephrology, Department of Internal Medicine and Clinical Research Institute, National Kyushu Medical Center, Fukuoka, Japan.
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Thomas P, Alptekin K, Gheorghe M, Mauri M, Olivares JM, Riedel M. Management of patients presenting with acute psychotic episodes of schizophrenia. CNS Drugs 2009; 23:193-212. [PMID: 19320529 DOI: 10.2165/00023210-200923030-00002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The initial management of patients with schizophrenia presenting to psychiatric emergency departments with an acute psychotic episode requires rapid decisions to be made by physicians concerning the treatment of individuals who are likely to be relatively uncooperative, agitated and lacking insight. The treatment decision must be adapted to the individual characteristics and needs of each patient. This article reviews the issues from the perspective of the initial management of acute psychosis as it is currently practised in Europe, and discusses the pragmatic implications for initial treatment decisions and the elaboration of a long-term treatment plan. Initially, administration of antipsychotics to control psychotic symptoms and benzodiazepines to control agitation represents the cornerstone of treatment. Oral medication is preferable to injectable forms wherever possible, and atypical antipsychotics are to be preferred over conventional agents because of their lower risk of extrapyramidal adverse effects, which are a major determinant of poor adherence to treatment. Whatever antipsychotic is chosen by the physician during the initial period, it is likely that it will need to be continued for many years, and it is thus important to take into account the long-term safety profile of the drug chosen, particularly in relation to extrapyramidal adverse effects, metabolic complications and quality of life. Building a therapeutic alliance with the patient and his/her family or carers is an important element that should be included in the initial management of psychosis. The long-term goal should be to minimize the risk of psychotic relapse through adequate treatment adherence.
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Affiliation(s)
- Pierre Thomas
- Department of Psychiatry, University of Lille Medical School, Lille, France.
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Seitz DP, Gill SS. Neuroleptic malignant syndrome complicating antipsychotic treatment of delirium or agitation in medical and surgical patients: case reports and a review of the literature. PSYCHOSOMATICS 2009; 50:8-15. [PMID: 19213967 DOI: 10.1176/appi.psy.50.1.8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse event associated with the use of antipsychotics. OBJECTIVE The authors provide information on the development and outcome of NMS during antipsychotic treatment of delirium or agitation in medically ill patients. METHOD The authors present case reports and a literature review of NMS arising during antipsychotic treatment of delirium. RESULTS A total of 25 cases of NMS occurring in patients with delirium or agitation were identified. Most cases involved men with agitated delirium who received relatively high doses of parenteral haloperidol. The signs and symptoms of NMS episodes were similar to those reported in other settings, and most patients had a complete recovery. CONCLUSION Clinicians utilizing antipsychotics in managing delirium or agitation are advised to be vigilant for NMS. Further study is required to determine whether certain patient characteristics or medications present greater risk for this serious adverse event.
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Affiliation(s)
- Dallas P Seitz
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.
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Vurucu S, Congologlu A, Altun D, Unay B, Akin R. Neuroleptic malignant syndrome due to risperidone treatment in a child with Joubert syndrome. J Natl Med Assoc 2009; 101:273-5. [PMID: 19331262 DOI: 10.1016/s0027-9684(15)30858-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Joubert syndrome is a rare autosomal recessive disease characterized by hypotonia, ataxia, episodic hyperpnea, psychomotor retardation, abnormal ocular movements, cerebellar vermian hypoplasia, and molar tooth sign on magnetic resonance imaging. Neuroleptic malignant syndrome is an uncommon and potentially fatal idiosynchratic reaction of antipsychotic drugs, in which the clinical scenario encompass muscular rigidity, hyperthermia, autonomic dysfunction, altered consciousness, high creatinine phosphokinase levels, and leukocytosis. This report describes a case of neuroleptic malignant syndrome due to risperidone in a child with Joubert syndrome.
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Affiliation(s)
- Sebahattin Vurucu
- Department of Pediatrics, Gulhane Military Medical Academy, Ankara, Turkey.
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Sheil AT, Collins KA, Schandl CA, Harley RA. Fatal Neurotoxic Response to Neuroleptic Medications. Am J Forensic Med Pathol 2007; 28:116-20. [PMID: 17525560 DOI: 10.1097/paf.0b013e31805c93d0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neuroleptic malignant syndrome (NMS) is a diagnosis of exclusion difficult to make due to a lack of pathognomonic features. Diagnosing NMS by postmortem examination becomes increasingly challenging when possible underlying brain pathology is obscured. The diagnosis is based on clinical history and laboratory findings. Autopsy and histologic findings, if any, usually are reflective of hyperthermia or complications (eg, aspiration pneumonia) of NMS. The authors describe a case of a 36-year-old Hispanic woman with a presumptive diagnosis of pseudoseizures, treated with various combinations of neuroleptic medications over a 6-week period prior to her sudden, unexpected, in-hospital death. Neuroleptic malignant syndrome is likely to have contributed to this patient's death. Confounding factors and medicolegal issues of a postmortem diagnosis of NMS are discussed.
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Affiliation(s)
- Amy T Sheil
- Medical University of South Carolina, Charleston, South Carolina, USA
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Erermis S, Bildik T, Tamar M, Gockay A, Karasoy H, Ercan ES. Zuclopenthixol-induced neuroleptic malignant syndrome in an adolescent girl. Clin Toxicol (Phila) 2007; 45:277-80. [PMID: 17453880 DOI: 10.1080/15563650601031692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We present the case of a 14-year-old female who had many characteristics of neuroleptic malignant syndrome (NMS) without pyrexia following a single depot injection of 200 mg of zuclopenthixol. The patient presented with a change in mental status that had progressed over the preceding 48 hours. Subsequently, she became increasingly agitated and confused, and developed diffuse muscular rigidity, mutism, tremor, tachycardia, diaphoresis, sialorrhea, and incontinence. Results of laboratory tests showed elevated CPK levels, leukocytosis, and a low serum iron level. Bromocriptine and diazepam were used as initial treatment of a probable NMS and provided significant improvement. During the next seven days, she clinically improved but continued to exhibit emotional lability, logorrhea, elevated mood, and increased psychomotor activity. Therefore, bromocriptine and diazepam were discontinued and lorazepam and lithium were administered as treatment of a bipolar disorder. Four weeks later, she was discharged in stable condition. The presentation of this case report suggests that the primary psychiatric diagnosis is important in antipsychotic usage in the pediatric population, and that young patients receiving neuroleptic treatment should be monitored for the early signs of NMS. Using the diagnostic criteria of a neuroleptic toxicity spectrum may result in greater clinical awareness and earlier recognition of NMS.
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Affiliation(s)
- Serpil Erermis
- Department of Child Psychiatry, Ege University, School of Medicine, Izmir, Turkey
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Tsuchiya N, Morimura E, Hanafusa T, Shinomura T. Postoperative neuroleptic malignant syndrome that occurred repeatedly in a patient with cerebral palsy. Paediatr Anaesth 2007; 17:281-4. [PMID: 17263746 DOI: 10.1111/j.1460-9592.2006.02079.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A wide variety of neuroleptic agents are associated with neuroleptic malignant syndrome (NMS). However, the association between general anesthesia and NMS is uncertain. We report a case of a patient with cerebral palsy, who showed signs of NMS only after repeated general anesthesia. The patient received general anesthesia three times in a period of 9 months. The first anesthetic passed uneventfully. NMS symptoms were observed only after the second and third anesthetics. The NMS was effectively treated with IV dantrolene and the patient recovered on both occasions. Inhalational anesthetics, muscle relaxants and fentanyl were suspected as possible triggering factors for NMS. After examining the three anesthesia records and previous publications, we surmized that a nondepolarizing muscle relaxant was associated with NMS in this patient.
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Marco CA, Vaughan J. Emergency management of agitation in schizophrenia. Am J Emerg Med 2005; 23:767-76. [PMID: 16182986 DOI: 10.1016/j.ajem.2005.02.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2005] [Revised: 02/20/2005] [Accepted: 02/25/2005] [Indexed: 10/25/2022] Open
Abstract
Schizophrenia is a common psychiatric condition, affecting approximately 1% of the population. Acute emergent presentations often include hallucinations, delusions, thought, and speech disorders. Agitation is common among emergency patients with schizophrenia. Decisional capacity should be assessed in all patients. Reversible causes of agitation should be ruled out, including infection, metabolic disorders, endocrine disorders, trauma, pain, noncompliance, toxicological disorders, and structural brain abnormalities. Agitation may be managed acutely using a combination of pharmacological agents and nonpharmacological interventions. Effective pharmacological agents include several classes of antipsychotic agents and benzodiazepines. Potential life-threatening complications of pharmacological therapy should be anticipated, which may include neuroleptic malignant syndrome (NMS), prolonged QT syndrome, and respiratory depression. Nonpharmacological interventions may include a quiet environment, physical restraints, and behavioral interventions. Disposition decisions should be made based on the etiology of agitation, effective management, decisional capacity, and presence of suicidal or homicidal intentions. Many patients who have required nonpharmacological or pharmacological management of agitation require inpatient psychiatric treatment, either voluntarily or involuntarily. Psychiatric consultation should be sought for patients with schizophrenia and uncertain disposition determinations, or those requiring other complex management decisions.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, St Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
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Untersuchungen zur Bestimmung und Stabilität von Risperidon in Körperflüssigkeiten und postmortalen Gewebeproben. Rechtsmedizin (Berl) 2005. [DOI: 10.1007/s00194-005-0328-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nagamine M, Yoshino A, Sakurai Y, Sanga M, Takahashi R, Nomura S. Exacerbating factors in neuroleptic malignant syndrome: comparisons between cases with death, sequelae, and full recovery. J Clin Psychopharmacol 2005; 25:499-501. [PMID: 16160631 DOI: 10.1097/01.jcp.0000178419.45179.cc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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