A rare case of neuroleptic malignant syndrome without elevated serum creatine kinase

Neuroleptic Malignant Syndrome Improved with Intramuscular Administration of the Anticholinergic Agent, Biperiden

Anticholinergic drugs, such as biperiden, benztropine, and diphenhydramine, were used for neuroleptic malignant syndrome (NMS) in the 1980s and 1990s. However, they have not been recommended for pharmacotherapy in NMS since 2000, as they may prevent a decrease in body temperature by suppressing sweating. However, whether anticholinergic drugs actually exacerbate NMS remains unclear. This study highlights the usefulness of anticholinergic drugs, which are no longer attracting attention as current pharmacological treatments for NMS. I treated four NMS patients using anticholinergic drugs. Two patients were treated with biperiden alone, and the other two patients were treated with a combination of biperiden and other drugs, including dantrolene, amantadine, or diazepam. Intramuscular injection of biperiden improved muscle rigidity, tremors, dysphagia, and akinetic mutism. Psychiatrists are familiar with anticholinergic drugs as they are used for antipsychotic-induced akathisia and Parkinsonism. My study suggests that anticholinergic drugs, especially injectable formulations, can be a therapeutic option for NMS.

Exceptionally high creatine kinase levels in risperidone-induced neuroleptic malignant syndrome: A case report

Neuroleptic malignant syndrome is a rare, fatal antipsychotic-induced idiosyncratic reaction characterised by hyperthermia, altered consciousness, autonomic instability and rigidity with elevated creatine kinase levels and leukocytosis. Neuroleptic malignant syndrome and antipsychotics are significant causes for elevated creatine kinase among the extensive list of differential diagnoses. Risperidone is an atypical antipsychotic drug with anti-serotonergic and anti-dopaminergic properties which has a wide range of side effects, including neuroleptic malignant syndrome. Though the rise in creatine kinase in neuroleptic malignant syndrome is commonly around 2000 to 15,000 IU/L due to myonecrosis, ischaemia and heat production, normal creatine kinase levels in neuroleptic malignant syndrome were also reported. Up to now, only two cases have been reported with creatine kinase levels of more than 50,000 IU/L in neuroleptic malignant syndrome, but neither of them was risperidone-induced. We report the first case of an exceptional rise in creatine kinase levels more than 250-fold in a 16-year-old girl following low-dose risperidone-induced neuroleptic malignant syndrome.

Neuroleptic malignant-like syndrome associated multiple system atrophy: report on three cases

Background

Multiple system atrophy (MSA) associated with neuroleptic malignant-like syndrome (NMLS) is rare and few cases have been described in the literature.

Case presentation

In the present study, three patients with MSA associated with NMLS were analyzed from January 2012 to January 2020 to characterize their clinical presentations. Data collected from the patients for analysis included general patient history, the fluctuation and severity of disease symptoms, the indicated therapies and disease progression at follow-up. All patients had histories of sudden withdrawal or reduction of levodopa prior to the onset of symptoms. Clinical presentations were characterized by hyperthermia, autonomic dysfunction, worsening of extrapyramidal symptoms, and elevated serum creatine kinase (CK) levels. During hospitalization, one patient rapidly progressed and died, while the other two patients were successfully treated.

Conclusions

Early diagnosis and treatment are very important for patient outcomes in NMLS. Notably, the correct dose and time of administration of dopaminergic medication may be key in treating NMLS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02583-8.

Electroconvulsive Therapy for Parkinson's Disease with Depression and Neuroleptic Malignant Syndrome: A Case Report

Parkinson's disease is often complicated by psychiatric symptoms. Psychiatrists are caught in a dilemma between such symptoms and physical treatment since Parkinson's disease sometimes shows treatment resistance based on pharmacological treatment-induced dopamine dysfunction. Here, we report on a 64-year-old woman with a 15-year history of Parkinson's disease with stage IV severity based on the Hoehn and Yahr scale. She was admitted to our hospital with a diagnosis of major depressive disorder with psychotic features. Unfortunately, her treatment course for depression was complicated by neuroleptic malignant syndrome. Because we were concerned about the persistence of her depressive symptoms, the risk of psychotropic drugs causing adverse effects, and progressive disuse syndrome, we administered modified electroconvulsive therapy. Her symptoms of neuroleptic malignant syndrome and depression sufficiently improved after five sessions of modified electroconvulsive therapy. Additionally, the primary motor symptoms of her Parkinson's disease also markedly improved. The improvement of neuroleptic malignant syndrome and her motor symptoms based on dopamine dysfunction can be explained by electroconvulsive therapy's effectiveness in activating dopamine neurotransmission. Besides, the marked improvement of her depressive episode with psychotic features was presumed to involve dopamine receptor activation and regulation. Because advanced Parkinson's disease can sometimes be refractory to treatment based on pharmacological treatment-induced dopamine dysfunction, psychiatrists often have difficulty treating psychiatric symptoms; electroconvulsive therapy may stabilize the dopaminergic system in such cases, presenting a possible non-pharmacologic treatment option for Parkinson's disease.

Development of Neuroleptic Malignant Syndrome in a Patient with Lewy Body Dementia after Intramuscular Administration of Paliperidone

Neuroleptic malignant syndrome (NMS) is a potentially fatal diagnosis composed of hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability. This syndrome has significant systemic complications including acute renal failure, rhabdomyolysis, hyperkalemia, and seizure. It is associated with the use of both typical and atypical antipsychotics. Due to the extensive neurodegenerative destruction of dopaminergic and acetylcholinergic pathways, patients with Lewy body dementia (LBD) are particularly sensitive to antidopaminergic and anticholinergic medications, making them more susceptible to extrapyramidal side effects and NMS. We present a case of a 72-year-old female with LBD who developed muscular rigidity, vital sign instability, and altered mental status after receiving one dose of paliperidone palmitate injection two weeks prior to admission. Initial blood work was unrevealing. Extensive workup including EEG, lumbar puncture with cerebrospinal fluid analysis, and brain MRI was unremarkable. She was treated with seven days of bromocriptine and a lorazepam taper with improvement in muscle rigidity. However, her mental status never improved, and she remained comatose. She was later intubated for airway protection after an aspiration event that led to hypoxia. Her respiratory status never recovered, and she was transitioned to comfort care. This case demonstrates the complexity and potential fatality of NMS. Clinicians should be aware of this dangerous complication of antipsychotic use in patients with LBD as these patients may be more susceptible to this complication.

Creatine kinase elevation and discontinuation of clozapine: fear-driven clinical practice in a forensic case with treatment-resistant schizophrenia and persistent violent behaviour

In forensic settings, the most common indication for clozapine is treatment-resistant schizophrenia (TRS). Clozapine has also been shown to be effective in reducing hostility, aggression and violence in patients with schizophrenia and is of benefit in comorbid substance use disorders. The decision to initiate or to discontinue recently initiated clozapine can have a profound beneficial or detrimental influence on the lives and safety of patients and the staff caring for them. We present a case in which treatment with clozapine proved effective in spite of earlier repeated discontinuation of clozapine out of fear of neuroleptic malignant syndrome (NMS). Elevation of creatine kinase was deemed to be indicative of NMS in the absence of clinical signs of NMS. In somatic medicine, it is well known that creatine kinase elevation has many causes, most of them non-harmful. Collaboration with clinical chemistry was shown to be very useful, if not essential; research in the 1980s found replicated evidence for both sex and race differences in creatine kinase levels. In addition, substantial intra-individual variation has been found over time in healthy individuals. The creatine kinase levels of this patient of African descent were within normal limits for the African population. Baseline creatine kinase assessment and repetition of this assessment after 2 weeks with careful interpretation are recommended in all clozapine-treated patients. The authors advocate the introduction of evidence-based creatine kinase cut-off points that reflect the biological differences between the sexes and among races. More intensive contact between psychiatrists and clinical chemist can facilitate faster diagnosis and better treatment.

Coexistence of guanidinoacetate methyltransferase (GAMT) deficiency and neuroleptic malignant syndrome without creatine kinase elevation

We describe the first child with guanidinoacetate methyltransferase (GAMT) deficiency who developed neuroleptic malignant syndrome (NMS) after the treatment of risperidone without elevated creatine kinase (CK) levels. The patient presented with lethargy, hyperthermia, generalized tremor and rigidity with normal serum CK levels. After cessation of risperidone and adding clonezepam to the supportive treatment, symptoms of NMS were ameliorated. We conclude that although serum CK elevation is a useful indicator for the early detection of NMS, normal serum CK levels may be seen during the NMS course in the presence of GAMT deficiency.

Neuroleptic malignant-like syndrome causing thrombocytopaenia: a rare association

Neuroleptic malignant-like syndrome is a rare but potentially fatal complication of sudden withdrawal of dopaminergic drugs. Clinical features are similar to that of neuroleptic malignant syndrome (NMS) like hyperthermia, autonomic dysfunction, altered sensorium, muscle rigidity; but instead of history of neuroleptic use, there is history of withdrawal of dopaminergic drugs. Laboratory examination generally show elevated creatine phosphokinase levels and may show elevated total leucocyte count. Thrombocytopaenia has been very rarely reported with NMS but it has not been reported with NM-like syndrome. Here, we discuss a case of Parkinson's disease which presented with typical clinical features and risk factors of NM-like syndrome associated with thrombocytopaenia and type 1 respiratory failure. He was treated with bromocriptine and supportive care. Thrombocytopaenia and respiratory failure resolved with above treatment. The patient improved clinically and was successfully discharged on day 12 of admission.

Neuroleptic Malignant Syndrome Associated With Metoclopramide Use in a Boy: Case Report and Review of the Literature

Neuroleptic malignant syndrome (NMS), an idiosyncratic reaction comprising muscular rigidity, altered level of consciousness, and autonomic dysfunction, is a rare but serious medical condition. It is most commonly precipitated by major tranquilizers such as butyrophenones, phenothiazines, and thioxanthines. Metoclopramide, a chlorbenzamide derivative with antidopaminergic properties, is widely used to treat nausea and emesis. We describe the first reported case of a boy who developed NMS in association with the use of this drug. A 13-year-old boy presented to the emergency department with a history of hyperthermia (42.6°C) and altered level of consciousness. He had recently had acute gastroenteritis and had been treated with metoclopramide 10 mg three times a day for 2 days. Vital signs were notable for hypotension, and physical examination revealed altered mental status with muscle rigidity. Laboratory testing revealed metabolic acidosis and increased prothrombin and partial thromboplastin times. He was actively cooled and received 3 rapid boluses, totaling 60 mL/kg, of isotonic crystalloids, for more than 20 minutes. Sepsis workup revealed no evidence of bacterial infection. He subsequently recovered fully and was discharged home with pediatric follow-up. This case represents the first description of NMS in association with metoclopramide in a healthy boy. It demonstrates the importance of considering this diagnosis early in the course of disease in patients with muscular rigidity, altered level of consciousness and autonomic dysfunction, and the need to rapidly respond to the physiological aberrations.

Neuroleptic malignant syndrome: an easily overlooked neurologic emergency

Neuroleptic malignant syndrome is an unpredictable iatrogenic neurologic emergency condition, mainly arising as an idiosyncratic reaction to antipsychotic agent use. It is characterized by distinctive clinical features including a change in mental status, generalized rigidity, hyperpyrexia, and dysautonomia. It can be lethal if not diagnosed and treated properly. Mortality and morbidity attributed to this syndrome have recently declined markedly due to greater awareness, earlier diagnosis, and intensive care intervention. In most cases, the syndrome occurs as a result of a rapid increase in a dose of neuroleptic, especially one of the long-acting ones. Pathophysiology behind this syndrome is attributed to a dopamine receptor blockade inside the neurons rendered by the offending drug and excessive calcium release from the sarcoplasmic reticulum of skeletal myocytes. Laboratory tests, although not diagnostic, may assist in assessing the severity of the syndrome and also the consequent complications. The syndrome has been described in all age groups and occurs more in males than in females. Genetics appears to be central regarding the etiology of the syndrome. Stopping the use of the offending agent, cold intravenous fluids, and removal of the causative agent and its possible active metabolites is the cornerstone of treatment. Periodic observation of psychotic patients recently started on antipsychotic medications, especially those being treated with depot preparations, may aid to an early diagnosis of the syndrome and lead to early treatment.