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Szota AM, Radajewska I, Araszkiewicz AS. Atypical Neuroleptic Malignant Syndrome: Case Reports and Diagnostic Challenges. J Psychoactive Drugs 2021; 54:284-293. [PMID: 34340640 DOI: 10.1080/02791072.2021.1957188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neuroleptic malignant syndrome caused by atypical antipsychotic drugs may present in an atypical manner without symptoms such as hyperthermia and/or muscle rigidity. A detailed description of atypical neuroleptic malignant syndrome induced by atypical antipsychotic drugs, practical information to distinguish neuroleptic malignant syndrome from other related conditions, and the diagnostic criteria that may be used to settle the diagnosis of atypical neuroleptic malignant syndrome are highlighted in this paper. This study was conducted searching PubMed and Science Direct, resulting in 525 articles. 26 case reports that met inclusion criteria were identified. Atypical neuroleptic malignant syndrome was found to develop mainly in male patients suffering from schizophrenia (14 cases) and bipolar disorder (2), and was induced by clozapine (6 cases), olanzapine (5 cases), aripiprazole and quetiapine (4 cases). Muscle rigidity did not develop in patients treated with clozapine and quetiapine, whereas a lack of hyperthermia was common with aripiprazole and clozapine treatment. Atypical neuroleptic malignant syndrome is a difficult matter, especially when symptoms of hyperthermia or muscle rigidity is lacking, but using Levenson's or Adityanjee and Aderibigbe's criteria may increase it detectability, can permit earlier intervention and prevent development of life-threatening typical neuroleptic malignant syndrome.
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Affiliation(s)
- Anna Maria Szota
- Department of Psychiatry, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Izabela Radajewska
- Department of Psychiatry, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
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Serrano WC, Maldonado J. The Use of Physostigmine in the Diagnosis and Treatment of Anticholinergic Toxicity After Olanzapine Overdose: Literature Review and Case Report. J Acad Consult Liaison Psychiatry 2021; 62:285-297. [PMID: 34102130 DOI: 10.1016/j.jaclp.2020.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/24/2020] [Accepted: 12/27/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Second-generation antipsychotic agents are commonly used by clinicians for the treatment of various psychiatric and medical conditions. Despite their presumed safety, an overdose with olanzapine may lead to the development of anticholinergic toxicity. The anticholinergic toxidrome is characterized by both central and peripheral physical findings. Central anticholinergic syndrome, a term used to describe the symptoms that arise from reduced cholinergic activity in the central nervous system, is characterized primarily by signs and symptoms consistent with hyperactive delirium. Signs of peripheral anticholinergia include mydriasis and blurred vision, tremors, ataxia, fever/hyperthermia, flushed and dry skin, dry oral mucosa, decreased bowel sounds, constipation, and urinary retention, among other symptoms. In extreme cases, central anticholinergic syndrome can be associated with seizures, coma, respiratory failure, and cardiovascular collapse. OBJECTIVE To provide scientific evidence regarding the efficacy and safety of physostigmine use in cases of anticholinergic toxicity. METHODS We conducted a comprehensive review of the published literature on the symptoms, diagnosis, and treatment of anticholinergic toxicity. RESULTS Currently the recommended treatment for olanzapine overdose, as is the case of most severe anticholinergic toxicity cases, involves supportive care, along with cardiac, neurological, and respiratory status monitoring. In addition, we detail the symptoms characteristic of anticholinergic toxicity, using the case of a patient experiencing central anticholinergic syndrome after an overdose with olanzapine. CONCLUSION Physostigmine, a tertiary acetylcholinesterase inhibitor, can be used to assist in the both the diagnosis and management of severe anticholinergic toxicity associated with an olanzapine overdose, which might be applicable to the antimuscarinic toxidrome associated with the ingestion of agents with significant anticholinergic activity.
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Affiliation(s)
- Wilmarie Cidre Serrano
- Department of Psychiatry & Behavioral Sciences, Stanford University 401 Quarry Road, Stanford, CA
| | - Jose Maldonado
- Department of Psychiatry & Behavioral Sciences, Stanford University 401 Quarry Road, Stanford, CA.
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Abstract
Catatonia is an important phenomenon in both psychiatry and general medicine. This article provides an overview of the key aspects of catatonia, including clinical features, differential diagnoses, management and prognosis. The different types of catatonia, the position of catatonia in the psychiatric classificatory systems, use of catatonia rating scales and the association between catatonia and neuroleptic malignant syndrome are also covered. Abnormalities that have been hypothesised as being possible underlying mechanisms in catatonia are highlighted. The article aims to provide clinicians with a comprehensive update on the subject, with information derived from an extensive range of relevant references.
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Wargo KA, Gupta R. Neuroleptic Malignant Syndrome: No Longer Exclusively a “Neuroleptic” Phenomenon. J Pharm Technol 2016. [DOI: 10.1177/875512250502100505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To review the literature concerning the incidence of neuroleptic malignant syndrome (NMS) associated with the use of atypical antipsychotics. Data Sources: Cases were identified through a search of MEDLINE (1986–March 2004) using the terms neuroleptic malignant syndrome, antipsychotic, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Study Selection and Data Extraction: Case reports of possible NMS secondary to second-generation antipsychotics were selected for review. Reports meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for NMS were considered. Case reports in which 1 of the 2 major diagnostic criteria was met were also included in the analysis. Furthermore, at least one minor criterion was met. Case reports in which patients received traditional antipsychotics were excluded. Data Synthesis: NMS is a rare and sometimes fatal disease. Several theories exist as to how NMS develops, and an equally large amount of diagnostic criteria are available. However, the majority of available data are based on the first-generation neuroleptics and very few exist with regard to the second-generation antipsychotics. Conclusions: Although there are numerous case reports of NMS occurring secondary to the use of second-generation antipsychotics, the incidence has never been fully elucidated. While the reasons for this remain uncertain, not all cases of second-generation–induced NMS fulfill the diagnostic criteria established for traditional neuroleptics and therefore may not be reported as such.
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Affiliation(s)
- Kurt A Wargo
- KURT A WARGO PharmD, Assistant Clinical Professor of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL
| | - Rahul Gupta
- RAHUL GUPTA MD FACP, Assistant Professor of Internal Medicine, University of Alabama—Birmingham School of Medicine, Huntsville Regional Medical Campus, Huntsville, AL
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Syndrome malin des neuroleptiques et difficultés diagnostiques : à propos d’un cas. Encephale 2016; 42:277-80. [DOI: 10.1016/j.encep.2016.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 12/10/2014] [Indexed: 11/24/2022]
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Dixit S, Dutta MK, Namdeo M. A Rare Case of Myxedema Coma with Neuroleptic Malignant Syndrome (NMS). J Clin Diagn Res 2015; 9:VD01-VD03. [PMID: 26155541 PMCID: PMC4484133 DOI: 10.7860/jcdr/2015/13008.5868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/07/2015] [Indexed: 11/24/2022]
Abstract
Myxedema coma or hypothyroid crisis is an endocrine emergency and needs ICU management. Neuroleptic malignant syndrome (NMS) is another medical emergency which needs high degree of clinical suspicion else mortality can be high. There is a paradox in co existence of myxedema coma and NMS. While one is hypometabolic state another is hypermetabolic state and both can be precipitated by antipsychotics use. Hypothermia and flaccidity commonly expected in myxedema coma may mask fever and rigidity of classical NMS contributing to diagnostic problem and treatment delay. Scientific literature on coexistance of myxedema coma and NMS is sparse. We hereby report first case with coexisting myxedema coma and NMS in a patient of schizophrenia treated with antipsychotic, where classical symptoms of NMS were masked by myxedema coma. Prompt diagnosis and effective management by a team resulted in favourable outcome in our patient. This case is reported to alert intensive care physicians to atypical manifestations of NMS in presence of hypothyroidism.
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Affiliation(s)
- Siddharth Dixit
- Classified Specialist Psychiatry, Department of Psychiatry, Base Hospital, Delhi Cantt, Assistant Professor, Department of Psychiatry, Army College of Medical Science, New Delhi, India
| | - Manoj Kumar Dutta
- Classified Specialist Endocrinology, Base Hospital Delhi Cantt. Assistant Professor, Army College of Medical Science, New Delhi, India
| | - Mayank Namdeo
- DNB Resident, Department of Psychiatry, Base Hospital, Delhi Cantt, India
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Szota A, Ogłodek E, Araszkiewicz A. Fever development in neuroleptic malignant syndrome during treatment with olanzapine and clozapine. Pharmacol Rep 2014; 65:279-87. [PMID: 23744413 DOI: 10.1016/s1734-1140(13)71004-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 11/26/2012] [Indexed: 11/30/2022]
Abstract
Neuroleptic malignant syndrome (NMS) is the most dangerous life-threatening complication of antipsychotic medication. It's development is connected with the blockade of dopaminergic transmission (D2 receptors) in the nigrostriatal system of the brain. Fever is one of the main symptoms of this syndrome and it's elevation is due to the activation of the immune system. Numerous studies report that treatment with clozapine (doses 37.5-600 mg) or olanzapine (doses 10-25 mg) or the use of these drugs in polytherapy cause pyrexia between 37.8-40.6 °C. Additionally, levels of proinflammatory interleukins such as IL-6, IL-1,TNF-α were increased. The aim of this article is to describe how olanzapine and clozapine influence fever development in NMS, in relation to the dose of the drug taken by schizophrenic patients including changes in immunological system.
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Affiliation(s)
- Anna Szota
- Department of Psychiatry, University Hospital, Kurpińskiego 19, PL 85-096 Bydgoszcz, Poland
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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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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially severe idiosyncratic adverse reaction usually seen in the context of treatment with antipsychotic drugs. Although NMS is historically associated with the classic or 'typical' antipsychotic drugs, it is also a potential adverse effect of atypical antipsychotic drugs. The widespread use of atypical antipsychotic drugs highlights the need to examine the data relating to the symptomatology, diagnosis, classification and management of NMS with these newer agents. We used MEDLINE and EMBASE to identify NMS case reports and systematic reviews published to June 2008 related to the atypical antipsychotic drugs clozapine, olanzapine, risperidone, paliperidone, aripiprazole, ziprasidone, amisulpride and quetiapine. Case reports and reviews were systematically examined. Our review suggests that, in general, NMS associated with atypical antipsychotic drugs manifests in a typical manner. One notable exception is clozapine-induced NMS, which appears less likely to manifest with extrapyramidal features, including rigidity and tremor. The available literature highlights the divergence of opinion relating to the core diagnostic features of NMS and its conceptualization as a categorical versus dimensional disorder. Both these issues have relevance for the identification of atypical or milder forms of NMS, which are sometimes seen with atypical antipsychotic drugs.
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Affiliation(s)
- Julian N Trollor
- School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.
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Stoner SC, Berry A. Suspected Neuroleptic Malignant Syndrome During Quetiapine-Clozapine Cross-Titration. J Pharm Pract 2009; 23:69-73. [DOI: 10.1177/0897190009333412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroleptic malignant syndrome (NMS) is a physiologic phenomenon that has been associated with the use of both first- and second-generation antipsychotics resultant to their ability to block dopamine blockade in the basal ganglia and hypothalamic regions of the brain. The typical reaction involves the presentation of muscle rigidity, changes in mental status, temperature elevation, labile blood pressure, and elevations in creatinine kinase and white blood cell counts. The reaction is most often reported early in the course of therapy but is well documented to have the potential to occur at any point in time. Untreated NMS can be fatal, often from secondary causes such as deep venous thrombosis and pulmonary embolism. Treatment involves immediate discontinuation of the offending agent, supportive therapy of clinical symptoms, and may include the use of the skeletal muscle relaxant, dantrolene sodium, or the dopaminergic agents bromocriptine or amantadine. In this case, we present a patient who developed symptoms of NMS during the cross-taper and conversion from quetiapine to clozapine. The patient was treated for NMS; however, his clinical diagnosis was never able to be definitively determined as he was initially evaluated for septicemia and later treated for suspected bacterial infection with antibiotics, and clozapine-associated side effects cannot be ruled-out as a contributing source to the clinical presentation. The estimated Naranjo Scale score for this case report is 3.
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Affiliation(s)
- Steven C. Stoner
- University of Missouri–Kansas City, Kansas City
- Northwest Missouri Psychiatric Rehabilitation Center, St Joseph, Missouri
| | - Amy Berry
- Northwest Missouri Psychiatric Rehabilitation Center, St Joseph, Missouri
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Picard LS, Lindsay S, Strawn JR, Kaneria RM, Patel NC, Keck PE. Atypical Neuroleptic Malignant Syndrome: Diagnostic Controversies and Considerations. Pharmacotherapy 2008; 28:530-5. [DOI: 10.1592/phco.28.4.530] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Neuroleptic malignant syndrome (NMS) is a rare but potentially serious complication of neuroleptic drugs. It may vary in both presenting characteristics and severity. Several different criteria for diagnosis exist, and each differs from the others slightly. We describe a 66-year-old woman with chronic paranoid schizophrenia who was prescribed olanzapine along with several other psychiatric drugs and an antihypertensive drug. The patient displayed several characteristics of NMS during therapy with olanzapine, including fever, elevated creatine kinase level, leukocytosis, and mild muscle rigidity. When olanzapine was held, the signs and symptoms improved and then returned with rechallenge of olanzapine. For this reason, olanzapine was considered strongly associated with this patient's apparent NMS episode. The patient's beta-blocker therapy may have masked additional signs of NMS. In addition, the patient tolerated other neuroleptics that were started in the hospital after the suspected NMS episode. The variation among different diagnostic criteria makes this syndrome a challenging diagnosis at times, in particular when atypical antipsychotics are suspected as the causative agent.
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Affiliation(s)
- Nick B Norgard
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma 73117-5040, USA.
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Perlov E, Tebartz van Elst L, Czygan M, Bubl E, Ebert D. Serum creatine kinase elevation as a possible complication of therapy with olanzapine. Naunyn Schmiedebergs Arch Pharmacol 2005; 372:168-9. [PMID: 16200393 DOI: 10.1007/s00210-005-0004-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Accepted: 08/22/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Evgeniy Perlov
- Department Psychiatry and Psychotherapy, University Hospital of Freiburg, Hauptsrtasse 5, 79098, Freiburg, Germany.
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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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Abstract
Neuroleptic malignant syndrome is the rarest and the most serious of the neuroleptic induced movement disorders. Although potent neuroleptics are more frequently associated with NMS, atypical antipsychotic drugs may also be a cause of NMS. Three databases were searched using the terms 'olanzapine' and 'neuroleptic' 'malignant syndrome'. Case reports were selected and reviewed from among all articles that fulfilled the search criteria. Twenty six cases were reviewed. Twenty cases fulfilled the criteria published by Sachdev et al. Olanzapine was the most probable cause of NMS in 16 cases. The absence of rigidity was described in only two of 16 highly probable olanzapine induced NMS cases, which is not as often as it is reported in clozapine associated NMS (36%). It was found that prior NMS is an important risk factor in NMS.
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Affiliation(s)
- Ales Kogoj
- University Psychiatric Hospital, SI 1260 Ljubljana-Polje, Slovenia.
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Srivastava M, Brito-Dellan N, Davis MP, Leach M, Lagman R. Olanzapine as an antiemetic in refractory nausea and vomiting in advanced cancer. J Pain Symptom Manage 2003; 25:578-82. [PMID: 12782438 DOI: 10.1016/s0885-3924(03)00143-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nausea and vomiting are difficult symptoms to manage in patients with advanced cancer. Several classes of antiemetics are available, including phenothiazines, butyrophenones, substituted benzamides and selective serotonin antagonists, as well as corticosteroids. Most patients will respond to either single agents or combinations that frequently include corticosteroids. A minority of patients will have nausea that fails to respond. The atypical antipsychotic, olanzapine, relieves nausea in some patients failing to respond to the usual antiemetics. Two case reports are presented and the rationale for olanzapine's benefit is discussed.
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Affiliation(s)
- Manish Srivastava
- The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Berry N, Pradhan S, Sagar R, Gupta SK. Neuroleptic malignant syndrome in an adolescent receiving olanzapine-lithium combination therapy. Pharmacotherapy 2003; 23:255-9. [PMID: 12587815 DOI: 10.1592/phco.23.2.255.32091] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 16-year-old boy developed fever, generalized rigidity, leukocytosis, and increased serum transaminase and creatine kinase levels while receiving treatment with olanzapine and lithium. When both drugs were discontinued, his fever and rigidity subsided and biochemical irregularities spontaneously returned to normal, without any complications. Classic neuroleptic malignant syndrome (NMS) was diagnosed. Concomitant administration of lithium with olanzapine may place patients at risk for NMS. Clinicians need to be aware of this rare but potentially fatal side effect in patients of all ages, and especially in adolescents receiving both drugs.
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Affiliation(s)
- Neeraj Berry
- Department of Psychiatry, National Pharmacovigilance Centre, All India Institute of Medical Sciences, New Delhi, India
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Abstract
A review of the English literature confirms that neuroleptic malignant syndrome (NMS) occurs with both traditional and atypical antipsychotic medications. Published reports of NMS induced by the traditional antipsychotics have given the practitioner valuable information on the prevention and treatment of this adverse effect. Case reports have also been published concerning NMS and clozapine, risperidone, olanzapine and quetiapine. By evaluating the case reports of atypical antipsychotic-induced NMS, valuable information may be obtained concerning similarities or differences from that induced by the traditional antipsychotics. The case reports of NMS with atypical antipsychotics were evaluated for diagnosis, age/sex of patient, risk factors, antipsychotic doses and duration of use, symptoms of NMS, and clinical course.
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Affiliation(s)
- Debra K Farver
- South Dakota State University, South Dakota Human Services Center, PO Box 76, Yankton, SD 57078, USA.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:621-36. [PMID: 12462142 DOI: 10.1002/pds.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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