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Pötter-Nerger M, Löhle M, Höglinger G. Akinetic crisis and withdrawal syndromes: guideline "Parkinson's disease" of the German Society of Neurology. J Neurol 2024; 271:6485-6493. [PMID: 39192030 PMCID: PMC11447035 DOI: 10.1007/s00415-024-12649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/22/2024] [Accepted: 08/17/2024] [Indexed: 08/29/2024]
Abstract
The akinetic crisis is a well-known, rare, potentially life-threatening condition in Parkinson's disease with subacute worsening of akinesia, rigidity, fever, impaired consciousness, accompanying vegetative symptoms and transient dopa-resistance. The akinetic crisis was historically supposed to be a "withdrawal syndrome" in the sense of discontinuation of dopaminergic medication. Recently, other "withdrawal syndromes" as the specific "dopamine agonist withdrawal syndrome" or "deep brain stimulation withdrawal syndrome" have been described as emergency situations with specific subacute symptom constellations. All three conditions require immediate start of the adequate therapy to improve the prognosis. Here, the diagnostic criteria and treatment options of these three acute, severely disabling syndromes will be reported along the current guidelines of the German Parkinson Guideline Group.
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Affiliation(s)
- Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Matthias Löhle
- Department of Neurology, University Medicine Rostock, Rostock, Germany
- German Center for Neurodegenerative Diseases (DZNE), Rostock, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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2
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Pötter-Nerger M, Schrader C, Jost WH, Höglinger G. The akinetic crisis in Parkinson´s disease- the upper end of a spectrum of subacute akinetic states. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02817-8. [PMID: 39153024 DOI: 10.1007/s00702-024-02817-8] [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: 03/03/2024] [Accepted: 07/31/2024] [Indexed: 08/19/2024]
Abstract
The akinetic crisis is defined as an acute, potentially life-threatening, levodopa-resistant, severe aggravation of rigidity, severe akinesia, associated with high fever, disturbance of consciousness, dysphagia and autonomic symptoms often due to disruption of dopaminergic medication or infections. The akinetic crisis is a relatively rare event, however subacute mild-moderate motor symptom deterioration in Parkinson´s disease (PD) patients is a frequent cause of hospitalization. In this review, we propose that the akinetic crisis is the upper end of a continuous spectrum of acute akinetic states depending on the degree of the progressive levodopa-resistance. Clinical symptomatology, risk factors, and instrumental diagnostics as the DAT-SPECT reflecting a biomarker of levodopa-resistance will be discussed to evaluate the spectrum of akinetic states. Pathophysiological considerations about the potential role of proinflammatory cytokines on the progressive levodopa-resistance will be discussed and therapeutical, consensus-based guidelines will be presented.
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Affiliation(s)
- Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | | | - Wolfgang H Jost
- Center for Movement Disorders, Parkinson-Klinik Ortenau, Wolfach, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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3
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Connell J, Oldham M, Pandharipande P, Dittus RS, Wilson A, Mart M, Heckers S, Ely EW, Wilson JE. Malignant Catatonia: A Review for the Intensivist. J Intensive Care Med 2023; 38:137-150. [PMID: 35861966 DOI: 10.1177/08850666221114303] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Catatonia is a clinical syndrome characterized by psychomotor, neurological and behavioral changes. The clinical picture of catatonia ranges from akinetic stupor to severe motoric excitement. Catatonia can occur in the setting of a primary psychiatric condition such as bipolar disorder or secondary to a general medical illness like autoimmune encephalitis. Importantly, it can co-occur with delirium or coma. Malignant catatonia describes catatonia that presents with clinically significant autonomic abnormalities including change in temperature, blood pressure, heart rate, and respiratory rate. It is a life-threatening form of acute brain dysfunction that has several motoric manifestations and occurs secondary to a primary psychiatric condition or a medical cause. Many of the established predisposing and precipitating factors for catatonia such as exposure to neuroleptic medications or withdrawal states are common in the setting of critical illness. Catatonia typically improves with benzodiazepines and treatment of its underlying psychiatric or medical conditions, with electroconvulsive therapy reserved for catatonia refractory to benzodiazepines or for malignant catatonia. However, some forms of catatonia, such as catatonia secondary to a general medical condition or catatonia comorbid with delirium, may be less responsive to traditional treatments. Prompt recognition and treatment of catatonia are crucial because malignant catatonia may be fatal without treatment. Given the high morbidity and mortality associated with malignant catatonia, intensivists should familiarize themselves with this important and under-recognized condition.
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Affiliation(s)
- Jennifer Connell
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark Oldham
- University of Rochester Medical Center, Rochester, NY, USA
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Division of Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Wilson
- Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Mart
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wes Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Cedeno-Veloz B, Areosa Sastre A. [Neuroleptic malignant syndrome after withdrawal of levopoda]. Rev Esp Geriatr Gerontol 2018; 53:299-300. [PMID: 29628214 DOI: 10.1016/j.regg.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 01/23/2018] [Accepted: 02/05/2018] [Indexed: 06/08/2023]
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Raj K, Jajor TR, Khandelwal A, Goyal G. Neuroleptic Malignant Syndrome with Minimal Dose of Amisulpride. J Acute Med 2017; 7:122-124. [PMID: 32995183 PMCID: PMC7517911 DOI: 10.6705/j.jacme.2017.0703.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 11/10/2016] [Accepted: 12/05/2016] [Indexed: 06/11/2023]
Abstract
Amisulpride is an atypical antipsychotic drug, it helps in alleviation of symptoms of psychotic illnesses. Extrapyramidal features have been reported after taking amisulpride. Neuroleptic malignant syndrome (NMS) with amisulpride is rare, and have been reported earlier. In all the earlier reported cases patient received more than 150 mg of amisulpride. To the best of our knowledge we are reporting a case of NMS with very minimal dose of Amisulpride (50 mg) taken for very short period.
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Affiliation(s)
- Kishan Raj
- Institute of Brain and Spine Faridabad Consultant Neurology Haryana India
| | - T R Jajor
- Institute of Brain and Spine Faridabad Consultant Psychiatry Haryana India
| | - Ashish Khandelwal
- Institute of Brain and Spine Faridabad Consultant Psychiatry Haryana India
| | - Gaurav Goyal
- Mahatma Gandhi Medical College & Hospital Jaipur Department of Neurlogy Rajasthan India
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Kwei K, Frucht S. Acute Presentation of Nonmotor Symptoms in Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:973-986. [PMID: 28805591 DOI: 10.1016/bs.irn.2017.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There are a few syndromes involving the nonmotor symptoms of Parkinson's disease and other movement disorders that can quickly lead to severe morbidity and mortality, and, as such, need rapid identification and management. Among these are neuroleptic malignant syndrome, serotonin syndrome, dopamine agonist withdrawal syndrome, and dystonic storm. It is important to maintain a high index of suspicion for these disorders as lack of identification can lead to death. Many of these acutely occurring nonmotor syndromes are primarily the result of imbalances in dopaminergic and serotonergic systems due to changes in pharmacologic management of psychiatric disorders or Parkinson's disease. We discuss these acutely occurring nonmotor symptoms in order to raise awareness and also to highlight how these extremes in symptoms may uniquely shed light on the pathophysiology of Parkinson's disease.
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Affiliation(s)
- Kimberly Kwei
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Steven Frucht
- Icahn School of Medicine at Mount Sinai, New York, NY, United States.
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The effect of dopaminergic therapy on intraoperative microelectrode recordings for subthalamic deep brain stimulation under GA: can we operate on patients 'on medications'? Acta Neurochir (Wien) 2016; 158:387-93. [PMID: 26602236 DOI: 10.1007/s00701-015-2631-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Microelectrode recording (MER) plays an important role in target refinement in deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD). Traditionally, patients were operated on in the 'off-medication' state to allow intraoperative assessment of the patient response to direct STN stimulation. The development of intraoperative microelectrode recording (MER) has facilitated the introduction of general anaesthesia (GA). However, the routine withdrawal of dopaminergic medications has remained as standard practice. This retrospective review examines the effect of continuing these medications on intraoperative MER for subthalamic DBS insertion under GA and discusses the clinical implication of this approach. METHODS Retrospective review of PD patients who had bilateral STN DBS insertion was conducted. A cohort of seven patients (14 STN microelectrodes) between 2012 and 2013, who inadvertently underwent the procedure while 'on medication', was identified. This 'on-medication' group was compared to all other patients who underwent the same procedure between 2012 and 2013 and had their medications withdrawn preoperatively, the 'off-medication' group, n = 26 (52 STN DBS). The primary endpoint was defined as the number of microelectrode tracks required to obtain adequate STN recordings. A second endpoint was the length of MERs that was finally used to guide the DBS lead insertion. The Reduction of the levo-dopa equivalent daily dose (LEDD) was also examined as a surrogate marker for clinical outcome 12 months postoperatively for both groups. For the on-medication group further analysis of the clinical outcome was done relying on the change in the motor examination at 12 months following STN DBS using the following parameters (Hoehn and Yahr scale, the number of waking hours spent in the OFF state as well as the duration of dyskinesia during the ON periods). RESULTS The on-medication group was statistically comparable in all baseline characteristics to the off-medication group, including age at operation 57 ± 9.9 years vs. 61.5 ± 9.2 years, p = 0.34 (mean ± SD); duration of disease (11.6 ± 5 years vs. 11.3 ± 4 years, p = 0.68); gender F:M ratio (1:6 vs. 9:17, p = 0.40). Both groups had similar PD medication regimes preoperatively expressed as levodopa equivalent daily dose (LEDD) 916 mg (558-1850) vs. 744 mg (525-3591), respectively, p = 0.77. In the on-medication group, all seven patients (14 STN electrodes) had satisfactory STN recording from a single brain track versus 15 out of 26 patients (57.7 %) in the off-medication group, p = 0.06. The length of MER was 4.5 mm (3.0-5.5) in the on-medication group compared to 3.5 mm (3.0-4.5) in the off-medication group, p = 0.16. The percentage of reduction in LEDD postoperatively for the on-medication group was comparable to that in the off-medication group, 62 % versus 58 %, respectively, p > 0.05. All patients in the on-medication group had clinically significant improvement in their PD motor symptoms as assessed by the Hoehn and Yahr scale; the number of hours (of the waking day) spent in the OFF state dropped from 6.9 (±2.3) h to 0.9 (±1.6) h; the duration of dyskinesia during the ON state dropped from 64 % (±13 %) of the ON period to only 7 % (±12 %) at 12 months following STN DBS insertion. CONCLUSION STN DBS insertion under GA can be performed without the need to withdraw dompaminergic treatment preoperatively. In this review the inadvertent continuation of medications did not affect the physiological localisation of the STN or the clinical effectiveness of the procedure. The continuation of dopamine therapy is likely to improve the perioperative experience for PD patients, avoid dopamine-withdrawal complications and improve recovery. A prospective study is needed to verify the results of this review.
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Abstract
Movement disorder emergencies are defined as clinical scenarios where a movement disorder develops over hours to days, and in which morbidity and even mortality can result from failure to appropriately diagnose and manage the patient. The last decade has seen increasing recognition of various movement disorder emergencies, including acute parkinsonism, neuroleptic malignant syndrome, respiratory compromise in multiple system atrophy, dystonic storm, oculogyric crisis, and hemiballism, among others. This article will review the major movement disorder emergencies encountered in the hospital and office, emphasizing practical management and treatment.
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Affiliation(s)
- Steven J Frucht
- Department of Neurology, Mount Sinai School of Medicine, 5 East 98th Street, New York, NY, 10029, USA,
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Abstract
Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. It has been associated with virtually all neuroleptics, including newer atypical antipsychotics, as well as a variety of other medications that affect central dopaminergic neurotransmission. Although uncommon, NMS remains a critical consideration in the differential diagnosis of patients presenting with fever and mental status changes because it requires prompt recognition to prevent significant morbidity and death. Treatment includes immediately stopping the offending agent and implementing supportive measures, as well as pharmacological interventions in more severe cases. Maintaining vigilant awareness of the clinical features of NMS to diagnose and treat the disorder early, however, remains the most important strategy by which physicians can keep mortality rates low and improve patient outcomes.
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Affiliation(s)
- Brian D Berman
- Department of Neurology, University of Colorado Denver School of Medicine, Aurora, CO, USA
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12
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13
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Abstract
Movement disorder emergencies include any movement disorder which evolves over hours to days, in which failure to appropriately diagnose and manage can result in patient morbidity or mortality. It is crucial that doctors recognize these emergencies with accuracy and speed by obtaining the proper history and by being familiar with the phenomenology of frequently encountered movements. These disorders will be discussed based on the most common associated involuntary movement, either parkinsonism, dystonia, chorea, tics or myoclonus, and, when available, review the workup and treatment options based on the current literature.
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Akcali A, Savas L. Malignant Syndrome of Two Parkinson Patients due to Withdrawal of Drugs. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n1p77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Johnson D, Philip AZ, Joseph DJ, Varghese R. Risperidone-induced neuroleptic malignant syndrome in neurodegenerative disease: a case report. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2007; 9:237-8. [PMID: 17632663 PMCID: PMC1911173 DOI: 10.4088/pcc.v09n0311f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Daniel Johnson
- Department of Internal Medicine, Mary Breckinridge Hospital, Hyden, Kentucky
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Frucht SJ. Movement disorder emergencies. Curr Neurol Neurosci Rep 2005; 5:284-93. [PMID: 15987612 DOI: 10.1007/s11910-005-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
For the past 4 years, Dr. Stanley Fahn and I have given a course at the American Academy of Neurology annual meeting on the topic of movement disorder emergencies. The purpose of this review article is to summarize the topic and to present it to readers of this journal. The text of this article has appeared in nearly the same form as the Academy syllabus accompanying our course. It is being presented here so that readers of the journal may review the material.
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Affiliation(s)
- Steven J Frucht
- Department of Neurology, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, USA.
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Meigal A, Lupandin Y. “Thermoregulation-dependent component” in pathophysiology of motor disorders in Parkinson's disease? PATHOPHYSIOLOGY 2005; 11:187-196. [PMID: 15837163 DOI: 10.1016/j.pathophys.2005.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2005] [Revised: 02/11/2005] [Accepted: 02/11/2005] [Indexed: 11/17/2022] Open
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder characterised by motor symptoms (resting tremor, brady- or akinesia and muscle rigidity), and also by postural problems gait disorder and fatigue as well as behavioural and autonomic symptoms, including thermoregulatory impairment. These symptoms are strikingly similar with some motor phenomena, evoked by the whole body cooling, though the primary cause of PD and cold-induced symptoms are apparently different. The review is focused on the hypothesis that thermoregulatory mechanisms are involved in pathophysiology of motor disorders in PD. The comparative analysis provides some examples of analogy between PD and the state of cooling in respect with tremor, muscle hypertonus, postural reactions and impairment of gross and fine muscle performance. This analogy cannot be considered as specific, because in some normal conditions the motor system utilises identical strategy to compensate for motor deterioration, e.g. at fatigue and ageing. However, such motor phenomena, as neuroleptic malignant syndrome and paired discharges of motor units indicate that the "thermoregulation-dependent component" exists in the pathophysiology of PD. Data on the influence of the whole body cooling and heating on muscle performance, rigidity and tremor in PD patients also provide evidence for the involvement of thermoregulatory mechanisms in PD.
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Affiliation(s)
- Alexander Meigal
- Department of Human and Animal Physiology, Petrozavodsk State University, Lenin Street, 33, Petrozavodsk 185002, Republic of Karelia, Russia
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Gaig C, Martí MJ, Tolosa E, Gómez-Choco MJ, Amaro S. Parkinsonism–hyperpyrexia syndrome not related to antiparkinsonian treatment withdrawal during the 2003 summer heat wave. J Neurol 2005; 252:1116-9. [PMID: 15778809 DOI: 10.1007/s00415-005-0798-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Revised: 12/13/2004] [Accepted: 01/03/2005] [Indexed: 11/26/2022]
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Bhanushali MJ, Tuite PJ. The evaluation and management of patients with neuroleptic malignant syndrome. Neurol Clin 2004; 22:389-411. [PMID: 15062519 DOI: 10.1016/j.ncl.2003.12.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
NMS is a rare but fatal syndrome that needs to be considered in the perioperative period. Although many aspects remain unexplored and controversial, with greater awareness of the condition, new concepts are coming into light. Definitive treatment guidelines remain an important issue to be addressed. Efforts have been initiated in that direction and all cases can be reported on a toll-free hotline ( 1-888-667-8367) or online (www.nmsis.org).
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Affiliation(s)
- Minal J Bhanushali
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Mizuno Y, Takubo H, Mizuta E, Kuno S. Malignant syndrome in Parkinson's disease: concept and review of the literature. Parkinsonism Relat Disord 2003; 9 Suppl 1:S3-9. [PMID: 12735909 DOI: 10.1016/s1353-8020(02)00125-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We reviewed literature on malignant syndrome occurring in patients with Parkinson's disease (PD) during the course of drug therapy. Clinical features were high fever, marked rigidity, consciousness disturbance, autonomic dysfunction, and elevation of serum creatine kinase. The clinical features were essentially similar to those of neuroleptic malignant syndrome. The immediate triggering event was, most often, discontinuation or reduction of anti-parkinsonian drugs, particularly of levodopa. But no anti-parkinsonian drug was the exception to the induction of malignant syndrome. Serious complications were severe pneumonia, disseminated intravascular coagulation, and acute renal failure. Early treatment with intravenous fluid infusion and external body cooling are essential for good recovery. Bromocriptine and dantrolene sodium were used frequently. It has been claimed that they are effective; however, randomized controlled studies are needed to explicitly prove the efficacy of these drugs in malignant syndrome associated with PD.
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Affiliation(s)
- Yoshikuni Mizuno
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo, Tokyo 113-8421, Japan.
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Takubo H, Harada T, Hashimoto T, Inaba Y, Kanazawa I, Kuno S, Mizuno Y, Mizuta E, Murata M, Nagatsu T, Nakamura S, Yanagisawa N, Narabayashi H. A collaborative study on the malignant syndrome in Parkinson's disease and related disorders. Parkinsonism Relat Disord 2003; 9 Suppl 1:S31-41. [PMID: 12735913 DOI: 10.1016/s1353-8020(02)00122-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We report the results of a collaborative study on malignant syndrome (MS) that developed in patients being treated with levodopa and other anti-parkinsonian drugs. We analyzed clinical features, laboratory findings, precipitating events, and risk factors for poor outcome. The study was conducted in five centers in Japan. Patients who developed MS between January 1991 and December 1997 were included. The enrollment criteria used were the same as those for neuroleptic MS proposed by Levenson et al. (1985).A total of 99 episodes were encountered in 93 patients (72 with Parkinson's disease and 21 with secondary parkinsonism); one patient had four recurrences of MS and three patients had two recurrences. High fever was the most frequent clinical manifestation of MS followed by worsening of parkinsonism, and then altered levels of consciousness. Serum creatine kinase was abnormally elevated in all the patients studied. Life-threatening complications were rhabdomyolysis, disseminated intravascular coagulation, and acute renal failure. The most frequent precipitating event was discontinuation or dose reduction of anti-parkinsonian drugs, particularly levodopa. No drug was the exception in the precipitation of MS. Intercurrent infection was the next most common precipitating event. MS developed without drug withdrawal or infection in some patients. In five patients, severe "wearing off" phenomenon was the only event preceding the onset of MS. Hot weather and dehydration appeared to be the cause in three patients. Among the total of 99 episodes, patients recovered to the pre-MS state following 68 episodes (68.7%); in the remaining 31.3%, patients failed to recover to their previous state. Older age, higher Hoehn and Yahr stage during the symptomatic phase of MS, higher akinesia score, and the absence of wearing off phenomenon prior to developing MS were associated with poor outcome. The most frequently used treatments of MS were intravenous fluid, levodopa, dantrolene sodium, and intragastric bromocriptine. Early introduction of treatment is important. Any elevation of body temperature during the course of anti-parkinsonian drug treatment should be considered as MS until proved otherwise.
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Affiliation(s)
- Hideki Takubo
- Department of Neurology, Tokyo Rinkai Hospital, Tokyo, Japan
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Philibert RA, Adam LA, Frank FM, Carney-Doebbeling C. Olanzapine usage associated with neuroleptic malignant syndrome. PSYCHOSOMATICS 2001; 42:528-9. [PMID: 11815691 DOI: 10.1176/appi.psy.42.6.528] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- R A Philibert
- Department of Psychiatry, University of Iowa, Iowa City 52246, USA.
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Abstract
At no time in the past have the basic and clinical sciences applied to Parkinson's disease been so active. Experimental therapies under study at present promise to improve on the limitations of existing treatments. Future progress in understanding the causation and pathogenesis of the disorder will permit the development of new treatments that will slow, halt, or even reverse the currently inexorable progressive course of Parkinson's disease.
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Affiliation(s)
- A E Lang
- Department of Medicine, University of Toronto and the Toronto Hospital, Canada
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