Zuclopenthixol-induced neuroleptic malignant syndrome presenting as fever of unknown origin, hyperglycaemia and acute myocardial infarction in a 60-year-old man

A fatal case of fulminant neuroleptic malignant syndrome: A case report

Background

Neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening adverse reaction to treatment with antipsychotic drugs, is characterized by hyperthermia, muscle rigidity, impaired consciousness, and autonomic disturbances. Some reports have described rapidly progressing cases of NMS resulting in death within several days. This report describes a clinical course of fatal and fulminant NMS in a patient with schizoaffective disorder.

Case Presentation

A 67-year-old man had long been in a stable condition under antipsychotic pharmacotherapy. At 3 days before admission to our hospital, he complained of diarrhea, fatigue, and reduced appetite. On admission to our hospital, he showed fever, mild muscle rigidity at the four extremities, elevated heart rate, hypertension, excessive diaphoresis, and decreased percutaneous oxygen saturation (SpO2). He was diagnosed as having NMS. Within 3 days after the onset of NMS, he displayed severe hyperthermia up to 41.4°C and severe autonomic disturbances, including elevated heart rate and hypertension. Despite treatments with dantrolene and bromocriptine, he went into shock and died on the fourth day after admission.

Conclusion

The present case suggests that severe hyperthermia and severe autonomic disturbances at the early stage of the onset might be signs of fatal and fulminant NMS. It may be recommended that clinicians consider electro-convulsive therapy when treating fulminant NMS with these symptoms.

Neuroleptic malignant syndrome associated with the use of injection zuclopenthixol acetate

Zuclopenthixol is usually used in parental form to manage acute agitation and psychosis.[1] It has high affinity for dopamine D1 and D2 receptors. There are very few reports of Neuroleptic Malignant Syndrome (NMS) with use of zuclopenthixol monotherapy. In this case report, we present a 35 year old male with alcohol dependence, presented to the emergency with altered sensorium, fever and stiffness of limbs. He had history of receiving Injection Zuclopenthixol acetate 200 mg thrice over 24 hours. Within 12-14 hours of the last injection, patient developed features suggestive of NMS. On investigations he was found to have raised serum creatinine phosphokinase levels (839.9U/L; reference laboratory value: 26 to 308 U/L) and leukocytosis. In view of these features, he was diagnosed with NMS and was started on supportive management to address the dehydration and was given Thiamine 500 mg thrice daily. Additionally he was started on Tab. Bromocriptine 5 mg thrice daily and lorazepam 2 mg/day. With this intervention, his symptoms improved over the period of 1 week and tablet bromocriptine was tapered off, after 1 week of being asymptomatic.

Neuroleptic malignant syndrome associated with the use of injection zuclopenthixol acetate

Zuclopenthixol is available in two parenteral formulation,i.e., in the form of acetate and decanoate. It has high affinity for dopamine D1 and D2 receptors. There is limited literature of association of neuroleptic malignant syndrome with the use of zuclopenthixol monotherapy. These case reports have mostly implicated zuclopenthixol decanoate, and also zuclopenthixol acetate. In this report, we present a case of neuroleptic malignant syndrome associated with use of zuclopenthixol acetate.