Neuroleptic malignant syndrome in an adolescent after brief exposure to olanzapine

Neuroleptic malignant syndrome in children and adolescents: Systematic review of case reports

INTRODUCTION

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal drug adverse reaction. There are still few studies of this entity in the child-adolescent population.

OBJECTIVES

Describe the clinical, laboratory and therapeutic characteristics of children and adolescent patients with NMS. Analyse the grouping of symptoms present in NMS in the same population.

MATERIAL AND METHODS

A MEDLINE/PubMed search of all reported cases of NMS from January 2000 to November 2018 was performed and demographic, clinical, laboratory and therapeutic variables were identified. A factorial analysis of the symptoms was performed.

RESULTS

57 patients (42 males and 15 females) were included, (mean age 13.65 ± 3.89 years). The onset of NMS occurred at 11.25 ± 20.27 days with typical antipsychotics and at 13.69 ± 22.43 days with atypical antipsychotics. The most common symptoms were muscle stiffness (84.2%), autonomic instability (84.2%) and fever (78.9). The most common laboratory findings were CPK elevation and leucocytosis (42.1%). The most used treatment was benzodiazepines (28.1%). In the exploratory factorial analysis of the symptoms we found 3 factors: 1) "Catatonic" with mutism (0.912), negativism (0.825) and waxy flexibility (0.522); 2) "Extrapyramidal" with altered gait (0.860), involuntary abnormal movements (0.605), muscle stiffness (0.534) and sialorrhoea (0.430); and 3) "Autonomic instability" with fever (0.798), impaired consciousness (0.795) and autonomic instability (0.387).

CONCLUSIONS

NMS in children and adolescents could be of 3 types: catatonic, extrapyramidal and autonomic unstable.

Neuroleptic Malignant Syndrome in Children and Adolescents: Systematic Review of Case Reports

INTRODUCTION

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal drug adverse reaction. There are still few studies of this entity in the child-adolescent population.

OBJECTIVES

Describe the clinical, laboratory and therapeutic characteristics of children and adolescent patients with NMS. Analyse the grouping of symptoms present in NMS in the same population.

MATERIAL AND METHODS

A MEDLINE/PubMed search of all reported cases of NMS from January 2000 to November 2018 was performed and demographic, clinical, laboratory and therapeutic variables were identified. A factorial analysis of the symptoms was performed.

RESULTS

57 patients (42 males and 15 females) were included, (mean age 13.65±3.89 years). The onset of NMS occurred at 11.25±20.27 days with typical antipsychotics and at 13.69±22.43 days with atypical antipsychotics. The most common symptoms were muscle stiffness (84.2%), autonomic instability (84.2%) and fever (78.9). The most common laboratory findings were CPK elevation and leucocytosis (42.1%). The most used treatment was benzodiazepines (28.1%). In the exploratory factorial analysis of the symptoms we found 3factors: 1) "Catatonic" with mutism (0.912), negativism (0.825) and waxy flexibility (0.522); 2) "Extrapyramidal" with altered gait (0.860), involuntary abnormal movements (0.605), muscle stiffness (0.534) and sialorrhoea (0.430); and 3) "Autonomic instability" with fever (0.798), impaired consciousness (0.795) and autonomic instability (0.387).

CONCLUSIONS

NMS in children and adolescents could be of 3types: catatonic, extrapyramidal and autonomic unstable.

The Differential Diagnosis and Treatment of Catatonia in Children and Adolescents

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the etiologies associated with catatonia in children and adolescents• Evaluate the differential diagnosis of pediatric catatonia• Interpret the literature regarding the treatment of children and adolescents with catatonia OBJECTIVE: Pediatric catatonia is associated with many medical and psychiatric conditions. Mortality is high, and proper treatment can be lifesaving. Catatonia is increasingly recognized in pediatric populations, in which about 20% of cases are related to underlying medical conditions. To minimize morbidity, clinicians must rule out underlying disorders while simultaneously managing symptoms and causes. In our review we discuss (1) recommendations to aid rapid decision making, both diagnostic and therapeutic, (2) emergent conditions and management, (3) disorders associated with pediatric catatonia, including developmental, acquired, idiopathic, and iatrogenic etiologies, (4) available treatments, and (5) medicolegal considerations.

METHODS

Initial PubMed search without date constraints using MeSH terms related to pediatric catatonia, with subsequent searches on pertinent subtopics using PubMed and Google Scholar.

RESULTS

Pediatric catatonia is a dangerous but treatable neuropsychiatric condition. Psychiatrists need to be aware of differential diagnoses and to be able determine appropriate treatment within a short time frame. With prompt diagnosis and treatment, outcomes can be optimized.

CONCLUSION

Pediatric catatonia is underdiagnosed and requires rapid evaluation and management.

Olanzapine overdose is associated with acute muscle toxicity

Olanzapine is an atypical antipsychotic that is reported to cause myopathy and raised creatine kinase (CK) levels. The prevalence and severity of acute myopathy after deliberate olanzapine ingestion are unclear. Therefore, we reviewed casenotes from 64 consecutive patients admitted to our institution after olanzapine overdose. Overall, serum CK was higher than five times the upper limit of normal in 17% of patients. The prevalence of raised CK values was positively correlated with the stated quantity of olanzapine ingested, suggesting a dose-dependent relationship for acute muscle toxicity. There was an apparent delay of 12 hours or more between olanzapine ingestion and the occurrence of maximum CK. Despite the high prevalence of acute muscle toxicity after olanzapine ingestion, none of the patients developed renal failure.

Effects of risperidone on energy balance in female C57BL/6J mice

OBJECTIVE

To investigate the effect of risperidone on energy expenditure and weight gain in female C57BL/6J mice.

DESIGN AND METHODS

Body weight and composition, food intake, energy expenditure, and activity were determined weekly. mRNA expression of uncoupling protein 1 in brown adipose tissue, orexin, and brain-derived neurotrophic factor in the hypothalamus were quantified using real-time PCR.

RESULTS

Risperidone tended to induce a greater body weight gain (P = 0.052) and significantly higher food intake (P = 0.038) relative to the placebo-treated group. Risperidone-treated mice had a higher resting energy expenditure (P = 0.001) and total energy expenditure (TEE) (P = 0.005) than the placebo group. There were no effects of treatment, time, and treatment by time on non-resting (or activity-related) energy expenditure between groups. Risperidone-treated mice showed a significantly lesser locomotor activity than placebo-treated mice over 3 weeks (P < 0.001). Risperidone induced a higher UCP1 mRNA (P = 0.003) and a lower orexin mRNA (P = 0.001) than placebo.

CONCLUSION

Risperidone-induced weight gain is associated with hyperphagia and a reduction in locomotor activity in C57BL/6J mice. Additionally, higher total and resting energy expenditure were accompanied by higher levels of UCP1 mRNA in BAT. The increased TEE could not offset the total intake of energy through risperidone-induced hyperphagia, therefore resulting in weight gain in female C57BL/6J mice.

Rhabdomyolysis reported for children and adolescents treated with antipsychotic medicines: a case series analysis

OBJECTIVE

Rhabdomyolysis is a rare and potentially serious adverse drug reaction (ADR) to antipsychotic medicines. The aim of this study was to investigate the clinical circumstances surrounding the diagnosis of rhabdomyolysis in children and adolescents treated with antipsychotic medicines. We also critically reviewed individual case safety reports (ICSRs) of suspected ADRs to evaluate how clinically useful they can be in a case series analysis.

METHODS

This was a descriptive and an exploratory study. Published case reports and ICSRs from the World Health Organization (WHO) Global ICSR database, VigiBase, reported with rhabdomyolysis and antipsychotic medicines for patients ≤17 years years of age were described. Reporting patterns of ICSRs with rhabdomyolysis and antipsychotic medicines were explored in VigiBase for children and adolescents and for adults. The VigiBase ICSRs were also systematically evaluated regarding the report content.

RESULTS

Of the 26 evaluated reports, 6 co-reported neuroleptic malignant syndrome (NMS) and 20 reports concerned rhabdomyolysis in the absence of NMS. The reported suspected antipsychotic medicines for these 20 reports were olanzapine, risperidone, haloperidol, paliperidone, quetiapine, clozapine, cyamemazine, and aripiprazole. In VigiBase, rhabdomyolysis (in the absence of NMS) was reported more frequently with olanzapine relative to all reports for children and adolescents with antipsychotic medicines. In the range of events that preceded rhabdomyolysis, muscle pains and abdominal pain were commonly recorded to have started during the week prior to the diagnosis. Other preceding symptoms were general weakness and dark urine. Onset of rhabdomyolysis for most patients occurred at any time within 2 months of starting antipsychotic treatment, in several cases triggered by changes to the patient's drug therapy or known risk factors of rhabdomyolysis. It was found that ICSRs can contribute with additional information, but that access to free text and narratives were crucial in order to capture clinically useful features of rhabdomyolysis.

CONCLUSION

Monitoring of children and adolescents needs to be intensified during dose increases, or when a new, added, or switched antipsychotic medicine is introduced to their drug regimen, and during exposure to known risk factors for rhabdomyolysis. The development of seemingly nonserious events, such as abdominal pain, muscle pain, weakness, and dark urine, should be followed up during antipsychotic use, as they might be precursory events to rhabdomyolysis that eventually could develop into acute renal failure.

Memantine and catatonia: a case report and literature review

Catatonia is a movement disorder with various possible etiologies. The majority of cases are associated with an underlying mood or psychotic disorder, while others are caused by medical conditions. Currently, benzodiazepines are the first-line psychopharmacologic agents in the treatment of catatonia. However, several cases have been reported in which treatment with memantine proved to be effective. We present the case of a 92-year-old female with major depressive disorder and associated catatonic symptoms. In this case, the patient's symptoms remitted quickly after the initiation of memantine. We review the possible causes of catatonia and pharmacologic treatments for the condition and highlight the possible benefits of N-methylD-aspartic acid receptor antagonists such as memantine in the treatment of catatonia.

Neuroleptic malignant syndrome in children and adolescents on atypical antipsychotic medication: a review

OBJECTIVE

Neuroleptic malignant syndrome (NMS) is a severe iatrogenic complication of treatment with antipsychotic medication. The purpose of this report is to examine the published cases of NMS in children and adolescents receiving atypical antipsychotic medication and review early warning symptoms, risk factors, and treatment in this population.

METHOD

An extensive review of the literature from 1990 to 2008 was conducted via computerized searches (PubMed and Ovid) to identify case reports. Descriptive statistics were employed to describe our findings.

RESULTS

There were 23 episodes in 20 subjects, with ages ranging from 11 to 18 years. Increased creatine phosphokinase (CPK) was the most common finding (100%), followed by fever (78%), tachycardia (74%), rigidity (70%), and altered mental status (61%). The number of NMS symptoms ranged from 1 to 11 (mean 4.7 +/- 2.4) and positive laboratory findings ranged from 1 to 4 (2.2 +/- 1). The duration of NMS (mean 6.1 +/- 6.4 days) was one third of the duration associated with typical antipsychotics. Patients treated with bromocriptine had a shorter duration of illness, whereas the same was not true for those receiving dantrolene. In all cases, the NMS symptoms eventually resolved and there were no reported deaths or permanent sequelae.

CONCLUSIONS

NMS is a serious condition. Symptom presentation related to atypical agents differs from that seen with older antipsychotic medications.

Paediatric atypical antipsychotic monitoring safety (PAMS) study: pilot study in children and adolescents in secondary- and tertiary-care settings

BACKGROUND

In the UK, treatment with antipsychotic medications for children is usually initiated by specialists in secondary care. Recent studies have shown an increase in the prescribing of atypical antipsychotics in children. The severity of possible adverse effects to antipsychotics in adults has lead to awareness of the importance of investigating the potential adverse effects of these agents in children. Additionally, there have been many reports proposing that the newer atypical antipsychotics are associated with many of the same adverse effects seen with the older generation drugs in children. The aim of the Paediatric Atypical Antipsychotic Monitoring Safety (PAMS) study was to determine the feasibility of conducting a prospective targeted pharmacovigilance study to monitor adverse drug reactions (ADRs) associated with atypical antipsychotic therapy in children seen in secondary- and tertiary-care settings.

METHODS

Participants were identified from the clinical members of the UK Paediatric Psychopharmacology Groups in London and the West Midlands. Participating clinicians reported the number of patients (aged<or=18 years) taking atypical antipsychotic treatment who were under their care and any reportable ADRs experienced by these patients during the period September 2006-September 2007. Participants contributed data via password protected online data collection forms.

RESULTS

A total of 35 clinicians consented to participate in the study. However, data from 22 of the participating clinicians were excluded because of incomplete reporting. Data from the remaining 13 (37%) clinicians were eligible for the final analysis. There were 281 patients who received atypical antipsychotic treatment under the care of the 13 participating clinicians. From these 281 patients, 40 ADR reports (0.14 ADR reports per patient; 95% CI 0.10, 0.19) from 37 patients were entered into the database. Of the 37 patients, 13 experienced more than one ADR, bringing the total number of ADRs to 56 (0.20 ADR per patient; 95% CI 0.15, 0.25). The most commonly reported ADRs were weight gain, extrapyramidal symptoms and hyperprolactinaemia. Rare ADRs, including neuroleptic malignant syndrome, were also reported. The durations of atypical antipsychotic drug exposure were recorded for 54 of the 56 ADRs reported. The median duration of exposure was 42 days (interquartile range 23.25-90 days).

CONCLUSIONS

Our study demonstrates that a clinician-based targeted pharmacovigilance study on atypical antipsychotics in children provides useful qualitative data. However, this pilot study raised many methodological issues, which should be addressed for the study to be extended nationally. Specifically, significant funding is needed to improve the reporting rate and the overall data obtained. Furthermore, the study yielded a very high incidence of serious ADRs, thus supporting the need for a larger and improved pharmacovigilance study to evaluate the safety of atypical antipsychotics in children.

[Catatonia in a 14 year-old girl: treatment with clorazepam and carbamazepine, a 10-year follow-up]

INTRODUCTION

Child and adolescent catatonia has been poorly investigated. Moreover, diagnosis criteria only exist for adult psychiatry, and there are no therapeutic guidelines. The aim of this paper is to describe the case of a 14-year-old girl presenting an overlap between psychogenic and neuroleptic induced catatonia, acute treatment and ten year's follow-up.

CASE REPORT

A 14-year-old Caucasian French girl, Elsa, was admitted in February 1998 to a University adolescent mental health center with an acute psychotic disorder. She showed agitation, impulsivity (sudden engagement in inappropriate behaviour), paranoid delusions, visual and auditory hallucinations, diurnal and nocturnal urinary incontinence, lack of self-care, inadequate food intake because of fear of poisoning, and vomiting after meals leading to rapid weight loss of 5 kg. Clinical examination, laboratory tests, EEG and RMI were normal. Toxicological tests were negative. Her IQ, assessed six months before admission, was in the dull average range (70-75). Elsa was treated with loxapine 150 mg per day for one week without improvement and this was then replaced by haloperidol 30 mg per day. One week after the start of haloperidol her agitation, impulsivity, and hallucinatory symptoms decreased. Twenty four days after loxapine introduction and 17 days after the haloperidol, her condition deteriorated rapidly over less than 48 hours. She exhibited immobility, minimal response to stimuli, staring and catalepsy with waxy flexibility. The diagnosis of catatonia was established. Examination revealed tremulous extremities, tachychardia (110 pm) and apyrexia. Creatine phosphokinase levels were 106 UI/l (normal range 0-250). Human immunodeficiency virus, hepatitis, listeria and Lyme serology were negative. Cerebrospinal fluid analysis was normal. Haloperidol was stopped and intravenous clonazepam 5mg/kg was begun. It was not possible to obtain signed consent from the two parents for Electroconvulsive therapy. The patient was transferred to a pediatric intensive care unit. The treatment was standard parenteral nutrition, nursing, intravenous clonazepam 0.05 mg/kg, with regular attendance by a child psychiatrist. Elsa stayed three weeks in this condition. She then began to notice the child psychiatrist, and a few days later she was able to carry out simple requests. Elsa was transferred to an adolescent psychiatric unit. As soon as she could eat by herself again, carbamazepine 400mg per day was begun. Her agitation reduced at a carbamazepine level of 7 mg/l. One month later her condition was stable. However, language difficulties persisted for a further six months. One year after the episode she scored 66 on a repeat IQ test and her RMI was normal. She exhibited no significant residual symptoms except some cognitive impairment. She integrated into a special education facility. These attempts to stop the carbamazepine were followed by depressed mood, aggressiveness and impulsivity; carbamazepine was finally stopped successfully after seven years. Ten years later, Elsa is the mother of two young children and is able to take care of them. She has never had a relapse of her psychotic disorder or catatonic state.

DISCUSSION

The etiopathogenic diagnosis is problematic. Some indices in the familial history may suggest a traumatic event. But one to the total residual amnesia it was never confirmed, and traumatic catatonia are extremely rare. Normal CPK levels, with autonomic disturbance limited to tachycardia and the lack of resolution after discontinuance of medication, argues against a diagnosis of neuroleptic malignant syndrome (NMS). But CPK levels are non specific, and NMS without pyrexia has been described. The occurrence of the catatonic syndrome 21 days after the first dose of a neuroleptic could be diagnostic. This case involved a non organic catatonic psychosis followed by neuroleptic induced catatonia. Catatonia is described as a risk factor for the development of NMS and some consider NMS to be a variant of malignant catatonia. The interest of this report is (1) it reinforces the need to be cautious before prescribing neuroleptics in adolescents presenting with symptoms of catatonia; (2) the complete recovery from catatonia after treatment with intensive care and more than three weeks of intravenous clonazepam without the use of ECT and (3) the effectiveness of carbamazepine over a long period of follow-up. Although trials on carbamazepine in catatonia are published, there are no data available for the control of residual symptoms or the long term prognosis, especially in child and adolescent psychiatry.

Recognizing and monitoring adverse events of second-generation antipsychotics in children and adolescents

Although second-generation antipsychotics (SGAs) are used increasingly in children and adolescents, data on the effectiveness and safety in pediatric populations are still sparse. Much of the safety information is derived from studies conducted in adults. This derivation is problematic because children and adolescents are exposed to SGAs during a phase of unparalleled physical and psychologic development that can affect pharmacokinetic and pharmacodynamic drug actions, efficacy, and side-effect patterns. This article presents an overview of SGA-related side effects in children and adolescents and strategies to monitor health outcomes effectively in youngsters receiving SGAs.