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Wright MA, Guasp M, Lachner C, Day GS, Gombolay G, Titulaer MJ, Clardy SL. Electroconvulsive therapy in N-methyl-d-aspartate receptor encephalitis: A retrospective cohort and scoping review of literature. J Neuroimmunol 2024; 392:578369. [PMID: 38823118 DOI: 10.1016/j.jneuroim.2024.578369] [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: 03/23/2024] [Revised: 05/04/2024] [Accepted: 05/12/2024] [Indexed: 06/03/2024]
Abstract
Neuropsychiatric symptoms in N-methyl-d-aspartate receptor encephalitis (NMDARE) have led some to pursue empiric trials of electroconvulsive therapy (ECT). A scoping review identified 39 patients diagnosed with NMDARE undergoing ECT. Separately, a retrospective cohort was reviewed to characterize 21 patients. Clinical improvement was attributed to ECT in 49% of patients in the scoping review and 19% of patients in the retrospective cohort; timing of immunotherapies was a confounding factor. Worsening of clinical course following ECT was reported in 28% of patients in the scoping review and 38% of patient in the retrospective review. There is currently insufficient data supporting a beneficial effect of ECT in NMDARE.
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Affiliation(s)
- Melissa A Wright
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
| | - Mar Guasp
- Service of Neurology, Hospital Clínic, University of Barcelona, Spain; Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Christian Lachner
- Division of Psychiatry, Mayo Clinic, Jacksonville, FL, USA; Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Grace Gombolay
- Emory University School of Medicine, Children's Healthcare of Atlanta, Department of Pediatrics, Division of Neurology, Atlanta, GA, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, USA; George E. Wahlen Veterans Affairs Health Care System, Salt Lake City, UT, USA
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Kutumbaka T, Varadan S, Sudagar Singh RB. The Atypical Face of Neuroleptic Malignant Syndrome: A Case Report of Ileus and Absent Rigidity. Cureus 2024; 16:e63784. [PMID: 39099918 PMCID: PMC11297847 DOI: 10.7759/cureus.63784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/06/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare life-threatening condition associated with the use of antipsychotic medications. This case report describes a male patient in his early 30s who presented with fever, breathlessness, and lower limb weakness, ultimately diagnosed with NMS despite the absence of muscular rigidity. On examination, he was febrile, tachycardic, and tachypneic with an oxygen saturation of 88% and elevated blood pressure. On auscultation diffuse crepitations in both lungs were revealed. Neurological assessment indicated motor strength of 3/5 in both lower limbs, without rigidity, sensory loss, or cerebellar signs. It was noted that he was on irregular atypical antipsychotic medication for the past one year. Laboratory investigations revealed leukocytosis, elevated transaminases, dyselectrolytemia, elevated creatine phosphokinase (CPK), and serum creatinine. NMS was not initially considered due to the lack of muscular rigidity. However, the patient later developed autonomic dysregulation manifestations, such as paralytic ileus. Once organic causes were excluded, NMS was diagnosed. Supportive therapy included 23 cycles of hemodialysis and colonic decompression for pseudo-obstruction. He was treated with intravenous fluids and dopamine receptor agonist medications. NMS usually presents with fever, muscular rigidity, altered mental status, and autonomic instability; yet, the absence of muscular rigidity in this patient is a distinctive and unusual feature.
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Affiliation(s)
- Tarun Kutumbaka
- General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Sivaprakash Varadan
- General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - R B Sudagar Singh
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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3
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Sweileh WM. Neuroleptic malignant syndrome and serotonin syndrome: a comparative bibliometric analysis. Orphanet J Rare Dis 2024; 19:221. [PMID: 38825678 PMCID: PMC11145872 DOI: 10.1186/s13023-024-03227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/27/2024] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVE This study aimed to analyze and map scientific literature on Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) from prestigious, internationally indexed journals. The objective was to identify key topics, impactful articles, prominent journals, research output, growth patterns, hotspots, and leading countries in the field, providing valuable insights for scholars, medical students, and international funding agencies. METHODS A systematic search strategy was implemented in the PubMed MeSH database using specific keywords for NMS and SS. The search was conducted in the Scopus database, renowned for its extensive coverage of scholarly publications. Inclusion criteria comprised articles published from 1950 to December 31st, 2022, restricted to journal research and review articles written in English. Data were analyzed using Microsoft Excel for descriptive analysis, and VOSviewer was employed for bibliometric mapping. RESULTS The search yielded 1150 articles on NMS and 587 on SS, with the majority being case reports. Growth patterns revealed a surge in NMS research between 1981 and 1991, while SS research increased notably between 1993 and 1997. Active countries and journals differed between NMS and SS, with psychiatry journals predominating for NMS and pharmacology/toxicology journals for SS. Authorship analysis indicated higher multi-authored articles for NMS. Top impactful articles focused on review articles and pathogenic mechanisms. Research hotspots included antipsychotics and catatonia for NMS, while SS highlighted drug interactions and specific medications like linezolid and tramadol. CONCLUSIONS NMS and SS represent rare but life-threatening conditions, requiring detailed clinical and scientific understanding. Differential diagnosis and management necessitate caution in prescribing medications affecting central serotonin or dopamine systems, with awareness of potential drug interactions. International diagnostic tools and genetic screening tests may aid in safe diagnosis and prevention. Reporting rare cases and utilizing bibliometric analysis enhance knowledge dissemination and research exploration in the field of rare drug-induced medical conditions.
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Affiliation(s)
- Waleed M Sweileh
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine.
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4
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Nakamura S, Iida A, Tsukahara K, Naito H. Successful Diagnosis of Neuroleptic Malignant Syndrome in an Unconscious Patient Using Amplitude-Integrated Electroencephalography: A Case Report. Cureus 2024; 16:e61927. [PMID: 38978900 PMCID: PMC11228452 DOI: 10.7759/cureus.61927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/10/2024] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare but life-threatening medical condition often characterized by altered consciousness and clinical features resembling seizures. This case report presents a unique and successful diagnosis of NMS in an unconscious patient with an unknown medical history. We demonstrate the potential utility of amplitude-integrated electroencephalography (aEEG) as a valuable tool for the differential diagnosis of seizure-like medical conditions, including NMS. The application of aEEG allowed for early diagnosis and prompt initiation of appropriate treatment, potentially contributing to improved patient outcomes.
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Affiliation(s)
- Shunsuke Nakamura
- Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, JPN
| | - Atsuyoshi Iida
- Advanced Emergency and Critical Care Center, Okayama University Hospital, Okayama, JPN
| | - Kohei Tsukahara
- Advanced Emergency and Critical Care Center, Okayama University Hospital, Okayama, JPN
| | - Hiromichi Naito
- Advanced Emergency and Critical Care Center, Okayama University Hospital, okayama, JPN
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Jan MZH, Figgs P, Gallucci G, Bacchus R. COVID-19 Pandemic-Delayed Diagnosis and Treatment of Atypical Neuroleptic Malignant Syndrome in a Violent Forensics Patient With Intellectual Disability and Treatment-Resistant Schizophrenia. Cureus 2023; 15:e41866. [PMID: 37581140 PMCID: PMC10423458 DOI: 10.7759/cureus.41866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
This case report highlights an episode of neuroleptic malignant syndrome (NMS) in a forensic psychiatry inpatient unit and how the coronavirus disease (COVID) pandemic, as well as, an atypical presentation of NMS delayed diagnosis and treatment of a patient, which could have been fatal. NMS and atypical NMS manifest typically after the use of anti-psychotics during the first two weeks of initiation of treatment. COVID can mimic many of the initial symptoms of NMS such as changes in mental status, fever, and, at times, dysautonomia. This case will try and highlight why this crossover of symptoms and the forensic environment made diagnosis and treatment in this particular case more difficult.
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Affiliation(s)
| | - Patricia Figgs
- Psychiatry and Behavioral Sciences, The Delaware Psychiatric Center, New Castle, USA
| | - Gerard Gallucci
- Psychiatry, The Delaware Psychiatric Center, New Castle, USA
| | - Romona Bacchus
- Psychiatry, The Delaware Psychiatric Center, New Castle, USA
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Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Watson CC, Shaikh D, DiGiacomo JC, Brown AC, Wallace R, Singh S, Szydziaka L, Cardozo-Stolberg S, Angus LG. Unraveling quad fever: Severe hyperthermia after traumatic cervical spinal cord injury. Chin J Traumatol 2023; 26:27-32. [PMID: 35177288 PMCID: PMC9912181 DOI: 10.1016/j.cjtee.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/05/2021] [Accepted: 01/02/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE There are many infectious and inflammatory causes for elevated core-body temperatures, though they rarely pass 40 ℃ (104 ℉). The term "quad fever" is used for extreme hyperpyrexia in the setting of acute cervical spinal cord injuries (SCIs). The traditional methods of treating hyperpyrexia are often ineffective and reported morbidity and mortality rates approach 100%. This study aims to identify the incidence of elevated temperatures in SCIs at our institution and assess the effectiveness of using a non-invasive dry water temperature management system as a treatment modality with mortality. METHODS A retrospective analysis of acute SCI patients requiring surgical intensive care unit admission who experienced fevers ≥ 40 ℃ (104 ℉) were compared to patients with maximum temperatures < 40 ℃. Patients ≥18 years old who sustained an acute traumatic SCI were included in this study. Patients who expired in the emergency department; had a SCI without radiologic abnormality; had neuropraxia; were admitted to any location other than the surgical intensive care unit; or had positive blood cultures were excluded. SAS 9.4 was used to conduct statistical analysis. RESULTS Over the 9-year study period, 35 patients were admitted to the surgical intensive care unit with a verified SCI. Seven patients experienced maximum temperatures of ≥ 40 ℃. Six of those patients were treated with the dry water temperature management system with an overall mortality of 57.1% in this subgroup. The mortality rate for the 28 patients who experienced a maximum temperature of ≤ 40 ℃ was 21.4% (p = 0.16). CONCLUSION The diagnosis of quad fever should be considered in patients with cervical SCI in the presence of hyperthermia. In this study, there was no significant difference in mortality between quad fever patients treated with a dry water temperature management system versus SCI patients without quad fever. The early use of a dry water temperature management system appears to decrease the mortality rate of quad fever.
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Affiliation(s)
- Carlton C.L. Watson
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA
| | - Dooniya Shaikh
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA
| | - Jody C. DiGiacomo
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA,Corresponding author.
| | - Aaron C. Brown
- American University of the Caribbean School of Medicine, Pembroke Pines, FL, 33027, USA
| | - Raina Wallace
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA
| | - Shridevi Singh
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA
| | - Lisa Szydziaka
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA
| | | | - L.D. George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, 1155, USA
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Edinoff AN, Mohammad-Amin H, Odisho AS. Silent Neuroleptic Malignant Syndrome: A Case Report of Atypical Antipsychotic Induced Elevation of Creatinine Kinase and Altered Mental Status. Health Psychol Res 2022; 10:37530. [PMID: 35999974 PMCID: PMC9392844 DOI: 10.52965/001c.37530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
34-year-old African American male with a diagnosis of schizophrenia was placed on aripiprazole and risperidone for psychosis and mood stabilization. Two days after medication initiation, the patient's mentation was altered and he appeared confused with an elevated creatine kinase (CK) at 7101. Medications were held and CK normalized with IV fluids. Quetiapine was initiated after medical stabilization along with lithium and paliperidone palmitate injections. After the second dose of paliperidone palmitate, the patient's mentation was altered, and repeat CK was 4272. The patient received 4 liters of IV fluid and his mental status returned to baseline. There were two case studies noted that had marked increases in serum CK with risperidone use. The first was in an adolescent who was titrated to a dose of risperidone 3mg/ day but the only abnormality was an increase in his CK levels. The next case report was in a 40-year-old female who was on risperidone 2.5mg /day for one year. She had an intention tremor, minor muscle weakness of the lower extremities with a blood pressure of 140/100 and a pulse of 100. She manifested more clinical signs of possible Neuroleptic Malignant Syndrome (NMS). This case highlights the importance of laboratory investigations when there is a high suspicion of possible NMS. It also highlights that some cases of NMS may only present as altered mental status and increased CK in which quick treatment may lead to the prevention of full-blown clinical manifestations of NMS which could be life-threatening.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital; Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport; Louisiana Addiction Treatment Center
| | - Hamza Mohammad-Amin
- Department of Psychiatry, Louisiana State University Health Science Center Shreveport
| | - Amira S Odisho
- Department of Psychiatry, Louisiana State University Health Science Center Shreveport
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Baeza-Trinidad R. Rhabdomyolysis: A syndrome to be considered. Med Clin (Barc) 2021; 158:277-283. [PMID: 34872769 DOI: 10.1016/j.medcli.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
Rhabdomyolysis is characterized by the release of intracellular elements after the destruction of skeletal muscle. Is characterized by the presence of muscle pain, weakness, and dark urine, associated with elevated creatine kinase (CK). The causes related to this syndrome are varied, being traumatic etiology, immobilization, sepsis, drugs and alcohol the most frequent. CK values are used for diagnosis and prognosis, being renal dysfunction the most serious complication. Treatment is based on early and intensive fluid therapy to avoid kidney complications.
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Hindmarsh J, Hindmarsh S, Lee M. Idiopathic Parkinson's Disease at the End of Life: A Retrospective Evaluation of Symptom Prevalence, Pharmacological Symptom Management and Transdermal Rotigotine Dosing. Clin Drug Investig 2021; 41:675-683. [PMID: 34213758 DOI: 10.1007/s40261-021-01054-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Distressing symptoms are prevalent in patients with idiopathic Parkinson's disease, yet little is known about symptom burden and subsequent pharmacological management at the end of life. Additionally, when oral administration of antiparkinsonian medications is no longer possible in dying patients, it is becoming common place to initiate transdermal rotigotine, despite a paucity of evidence to guide dosing. OBJECTIVES To assess: (1) symptom prevalence from the use of anticipatory medicines in patients with idiopathic Parkinson's disease, (2) the prescribing of antiparkinsonian medication at the end of life; and (3) the accuracy of conversion from oral antiparkinsonian medicines to transdermal rotigotine and any associations between rotigotine dosing and end-of-life symptoms. METHODS A retrospective case review was performed. One hundred consecutive patients with idiopathic Parkinson's disease who died during an inpatient admission at a UK teaching hospital were assessed. RESULTS The most prevalent terminal symptoms were excess respiratory secretions (58%), pain (52%), agitation (51%) and fever (23%). The majority of patients were converted to transdermal rotigotine (90%). Patients converted to a higher than equivalent dose of rotigotine were more likely to be agitated (p < 0.05), whilst those converted to a lower than equivalent dose were less likely to develop excess respiratory secretions (p < 0.05). The prevalence of pain did not differ according to rotigotine dosing. CONCLUSIONS This study highlights for the first time use of anticipatory medications at the end of life in patients with idiopathic Parkinson's disease and the prevalence of terminal symptoms. It also demonstrates the widespread use of rotigotine patches, and that lower than equivalent doses may be better tolerated.
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Affiliation(s)
- Jonathan Hindmarsh
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK.
- Department of Pharmacy, Sunderland Royal Hospital, South Tyneside and Sunderland Foundation Trust, Kayll Road, Sunderland, SR4 7TP, UK.
| | - Sharlene Hindmarsh
- Department of Pharmacy, Sunderland Royal Hospital, South Tyneside and Sunderland Foundation Trust, Kayll Road, Sunderland, SR4 7TP, UK
| | - Mark Lee
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK
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Piacenza F, Ong SK, O’Brien P, Clancy M. Neuroleptic malignant syndrome in a patient with moderate intellectual disability treated with olanzapine: A case report. Clin Case Rep 2021; 9:2404-2408. [PMID: 33936704 PMCID: PMC8077328 DOI: 10.1002/ccr3.4049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
This case demonstrates the challenges encountered in a case of Neuroleptic Malignant Syndrome in a young woman with moderate Intellectual Disability.
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Affiliation(s)
- Francesco Piacenza
- Department of Liaison PsychiatryUniversity Hospital WaterfordWaterfordIreland
| | - Suet Kee Ong
- Department of Liaison PsychiatryUniversity Hospital WaterfordWaterfordIreland
| | | | - Maurice Clancy
- Department of Liaison PsychiatryUniversity Hospital WaterfordWaterfordIreland
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Abstract
Acute presentation of new movement disorders and acute decompensation of chronic movement disorders are uncommon but potentially life-threatening. Inadvertent or purposeful overdose of many psychiatric medications can result in acute life-threatening movement disorders including serotonin syndrome, neuroleptic malignant syndrome, and malignant catatonia. Early withdrawal of potentiating medications, treatment with benzodiazepines and other diagnosis-specific drugs, and providing appropriate supportive care including airway and breathing management, hemodynamic stabilization, fluid resuscitation, and renal support including possible hemodialysis are the mainstays of acute management. Many of these conditions require admission to the neurologic intensive care unit.
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Oneib B, Zaimi O. Neuroleptic malignant syndrome: clinical expression, complication, course, and atypical clinical picture. MIDDLE EAST CURRENT PSYCHIATRY 2021. [DOI: 10.1186/s43045-020-00081-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Neuroleptic malignant syndrome (NMS) is an uncommon and lethal side effect of neuroleptics. The clinical expression of this syndrome is diverse. Even with criteria diagnosis, it is hard to recognize it easily.
We report a series of 25 cases of NMS among patients hospitalized in psychiatric service at Oujda for 5 years. We have described the clinical characteristics of NMS in these patients, the treatments received, the management, and the course of this syndrome.
Results
Most of the patients are hospitalized for psychotic or affective disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM V) criteria. 92% of patients received conventional neuroleptic, and half of them were under the injectable form. No patient took long-acting injectable antipsychotics. 36% of patients received neuroleptics for the first time. NMS appeared in the first week after the admission in psychiatric service among 24 patients. The most common clinical and biological signs were muscular rigidity, the elevation of creatine phosphokinase (CPK), and alteration of blood pressure. Other symptoms were found in proportion varied between 24% and 72%. 32% of the patients did not develop complications. One patient developed renal failure. All patients recovered, and no deaths were recorded.
Conclusions
Early recognition of NMS help to rescue patient. It is necessary to detect this syndrome even in the absence of main signs such as fever.
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A Mixed Presentation of Serotonin Syndrome vs Neuroleptic Malignant Syndrome in a 12-Year-Old Boy. Pediatr Emerg Care 2020; 36:e589-e591. [PMID: 29698346 DOI: 10.1097/pec.0000000000001477] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS) are serious medical conditions associated with commonly prescribed psychiatric medications. Although the mechanisms differ, they can be clinically difficult to distinguish. We report a case of a pediatric patient with complicated psychiatric history that developed features of both syndromes in the setting of polypharmacy. CASE A 12-year-old boy with a history of developmental delay, attention-deficit hyperactivity disorder, and posttraumatic stress disorder presented to the emergency department with behavior changes consisting of delayed reactions, gait instability, drooling, and slowed movements. Ten days before presentation, his outpatient psychiatrist had made multiple medication changes including discontinuation of cyproheptadine (an appetite stimulant) and initiation of aripiprazole. On arrival, the patient was noted to be tachycardia and hypertensive for age. He was disoriented, intermittently agitated, and tremulous with increased tonicity, clonus in the lower extremities, and mydriasis. He was supportively treated with lorazepam and intravenous fluids while discontinuing potential offending agents. His course was complicated by hypertension and agitation managed with dexmedetomidine infusion and benzodiazepines. His mental status, tremors, and laboratory values began to improve over the next 2 days, and eventually transitioned to the inpatient psychiatric unit on hospital day 7. DISCUSSION Diagnosis of NMS or SS can be difficult when there is overlap between syndromes, particularly in the setting of multiple potential offending agents or underlying developmental delay. In addition, pediatric patients may present atypically as compared with adult patients with the same condition. CONCLUSION The use of antipsychotic medications for young children with behavioral problems has risen dramatically in the last decade, increasing their risk for developing SS or NMS.
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Ortiz JF, Wirth M, Eskander N, Cozar JC, Fatade O, Rathod B. The Genetic Foundations of Serotonin Syndrome, Neuroleptic Malignant Syndrome, and Malignant Hyperthermia: Is There a Genetic Association Between These Disorders? Cureus 2020; 12:e10635. [PMID: 33123448 PMCID: PMC7584300 DOI: 10.7759/cureus.10635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS), serotonin syndrome (SS), and malignant hyperthermia (MH) share similar clinical characteristics. These conditions can present life-threatening situations due to exposure to different drugs. A similar genetic predisposition is suspected between these syndromes as well. This review aims to consolidate the knowledge about the genetics of these disorders and find possible correlations among them to frame the best possible approaches using different drugs without producing life-threatening complications that can be preventable. As a method, we collected data using PubMed with a Medical Subject Headings (MeSH) strategy. The inclusion criteria were as follows: full papers, studies conducted on humans, papers published in the English language, and study types that included case reports, journal articles, multicenter studies, clinical studies, observational studies, or clinical trials. Studies involving animals, articles that were without a visible abstract, study types that included clinical reviews, systematic reviews, or meta-analyses were excluded. 146 papers were reviewed, and 130 papers were removed for no possible extraction of data, duplication of the data, or the study outcome was not compatible with the objective of this review. Ultimately, a total of 17 papers were used for the discussion of this article. As a result of this review, we found no genetic association between NMS, SS, and MH development. Finally, we conclude that NMS, SS, and MH presentation are caused by different mutations which are not associated. 3However, because of the life-threatening clinical presentation of these conditions, genetic tests should be suggested in patients with a family history of these disorders before administering any pertinent drug that increases the risk of developing all these syndromes.
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Kuhlwilm L, Schönfeldt-Lecuona C, Gahr M, Connemann BJ, Keller F, Sartorius A. The neuroleptic malignant syndrome-a systematic case series analysis focusing on therapy regimes and outcome. Acta Psychiatr Scand 2020; 142:233-241. [PMID: 32659853 DOI: 10.1111/acps.13215] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening antipsychotic-associated disorder that requires an efficient and timely therapy. The aim of the study was to compare the effectiveness of different NMS therapies and to analyze its outcome depending on NMS severity. METHOD Systematic search for NMS cases in biomedical databases. The focus of the analysis was on therapy with dantrolene, bromocriptine, and electroconvulsive therapy (ECT) when each was compared with symptomatic therapy. Primary outcomes were the survival rate and the duration of treatment. RESULT 405 case reports were included. Overall, no statistically significant differences regarding mortality rate or duration of treatment were found between dantrolene, bromocriptine, or ECT compared to supportive care. A subgroup analysis regarding NMS severity showed that the mortality under specific NMS pharmacotherapy (dantrolene, bromocriptine) and under ECT was significantly lower than under purely symptomatic therapy in severe NMS (P = 0.018). The difference was not significant in mild and moderate cases. DISCUSSION An overall superiority of the specific NMS therapy (dantrolene, bromocriptine, and ECT) was not found in this study. When regarding severity classification, specific therapies were superior but only in severe cases, and ECT showed the lowest mortality rate. In previous case series, an effect on survival or the duration of the disease could only be observed in part for specific therapies, but the evidence available is inconsistent. The results of this study support our hypothesis that NMS treatment with dantrolene, bromocriptine, and ECT is advantageous over purely symptomatic therapy in severe NMS cases.
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Affiliation(s)
- L Kuhlwilm
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - C Schönfeldt-Lecuona
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - M Gahr
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - B J Connemann
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Ulm, Germany
| | - F Keller
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
| | - A Sartorius
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health (CIMH), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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van Rensburg R, Decloedt EH. An Approach to the Pharmacotherapy of Neuroleptic Malignant Syndrome. PSYCHOPHARMACOLOGY BULLETIN 2019; 49:84-91. [PMID: 30858642 PMCID: PMC6386430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Neuroleptic malignant syndrome is a rare, idiosyncratic emergency associated with exposure to dopamine antagonists, commonly antipsychotic drugs. The typical clinical picture consists of altered consciousness, muscular rigidity, fever, and autonomic instability. While the condition has generally been well described, the pathophysiology is still poorly understood. The importance of this case report is to highlight the lack of robust evidence-based treatment for this emergency. We submit an approach to the pharmacotherapy of neuroleptic malignant syndrome based on the available evidence.
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Affiliation(s)
- Roland van Rensburg
- Van Rensburg, MBChB Dip HIV Man(SA), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. Decloedt, MBChB BSc(Hons) FCCP(SA) MMed(Clin Pharm), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric H Decloedt
- Van Rensburg, MBChB Dip HIV Man(SA), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. Decloedt, MBChB BSc(Hons) FCCP(SA) MMed(Clin Pharm), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Abstract
Drugs can cause dysregulation of the hypothalamic–pituitary–adrenal axis which can result in a rise in core temperature This type of hyperthermia is unresponsive to antipyretics and can be complicated by rhabdomyolysis multi-organ failure and disseminated intravascular coagulation Organic causes of fever such as infection must be ruled out Syndromes associated with drug-induced fever include neuroleptic malignant syndrome and anticholinergic sympathomimetic and serotonin toxicity The class of offending drugs as well as the temporal relationship to starting or stopping them assists in differentiating between neuroleptic malignant syndrome and serotonin toxicity Immediate inpatient management is needed The mainstay of management is stopping the drug and supportive care often in the intensive care unit
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Affiliation(s)
- Nazila Jamshidi
- Royal Prince Alfred Hospital, Sydney.,NSW Poisons Information Centre, Sydney Children's Hospital Network
| | - Andrew Dawson
- Royal Prince Alfred Hospital, Sydney.,NSW Poisons Information Centre, Sydney Children's Hospital Network
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Vickery PB, Meadowcraft L, Vickery SB. Early detection of an atypical presentation of neuroleptic malignant syndrome: A case report. Ment Health Clin 2018; 7:137-142. [PMID: 29955512 DOI: 10.9740/mhc.2017.05.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS), which is considered a neurologic emergency, is believed to be caused by exposure to dopamine antagonist or withdrawal from a dopamine agonist. This article reports a case of suspected atypical NMS in a patient following rapid conversion of ziprasidone to risperidone without titration. While the initial presentation did not fully meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, diagnostic features, a sequential treatment strategy was initiated and the patient appropriately responded to antipsychotic cessation in addition to combination therapy with dantrolene and bromocriptine. Neuroleptic malignant syndrome diagnostic criteria, treatment, and prognosis are discussed.
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Affiliation(s)
- P Brittany Vickery
- Assistant Professor of Pharmacy Practice, Wingate University School of Pharmacy - Hendersonville Health Sciences Center, Hendersonville, North Carolina,
| | - Lindsy Meadowcraft
- Clinical Pharmacist, Charles George Veterans Affairs Medical Center, Asheville, North Carolina
| | - Stephen B Vickery
- Assistant Professor of Pharmacy Practice, Wingate University School of Pharmacy - Hendersonville Health Sciences Center, Hendersonville, North Carolina
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21
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Chen TR, Chen YC. Risperidone-Associated Neuroleptic Malignant Syndrome in an Inpatient With Schizophrenia, With Successful Rechallenge and 3 Year Follow-Up. Front Psychiatry 2018; 9:718. [PMID: 30618887 PMCID: PMC6305281 DOI: 10.3389/fpsyt.2018.00718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/06/2018] [Indexed: 11/13/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is rare but one of the most serious adverse effects of antipsychotics. Here, we report a case of risperidone-associated NMS in which a successful rechallenge of risperidone was observed with a positive follow-up. A 47-year-old female with schizophrenia was treated with risperidone 4 mg/d for 8 months in 2009 and was admitted to our hospital in 2015 owing to violent behavior under persecutory delusions. Risperidone 2 mg/d was initiated and increased to 4 mg/d 54 days later. Further, long-acting injectable (LAI) risperidone 25 mg per 2 weeks was added on hospital day 15. On hospital day 116, NMS occurred and thus we discontinued all antipsychotics including LAI risperidone, then NMS improved. We resumed LAI risperidone 25 mg per 2 weeks on hospital day 148, thus we waited for 22 days before re-starting the drug treatment. She was discharged on hospital day 371, then switched to LAI paliperidone 150 mg per 4 weeks 2 months later. At the time of a follow-up 3 years later, NMS had not reoccurred. This case reports on an unusual presentation of NMS in which no hyperthermia was observed. Furthermore, this case indicated that NMS may occur in a dose-dependent manner. In conclusion, this case reported important information for clinicians with regard to antipsychotic drug rechallenges and proper dosing of APs to avoid or reverse NMS.
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Affiliation(s)
- Ting-Ren Chen
- Department of Psychiatry, Chang Bing Show Chwan Memorial Hospital, Lukang, Taiwan.,Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.,Department of Psychiatry, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Ying-Chang Chen
- Department of Psychiatry, Show Chwan Memorial Hospital, Changhua, Taiwan
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22
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Velamoor R. Neuroleptic malignant syndrome: A neuro-psychiatric emergency: Recognition, prevention, and management. Asian J Psychiatr 2017; 29:106-109. [PMID: 29061403 DOI: 10.1016/j.ajp.2017.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 11/17/2022]
Abstract
Neuroleptic Malignant Syndrome (NMS) is a life threatening complication of antipsychotic therapy. It is often assumed to be rare. Observations suggest that rather than overestimating its frequency, we are more likely to underestimate it (Pope et al., 1986). It is a rare but potentially fatal disorder characterized by four principal symptoms. These are mental status changes, muscle rigidity, hyperthermia, and autonomic dysfunction. The diagnosis of NMS often presents a challenge because several medical conditions generate similar symptoms. Although less common now than in the past, thanks to greater awareness, it remains a risk in susceptible patients receiving conventional or atypical neuroleptics. Reducing the risk factors, early recognition of suspected cases, and prompt management can significantly reduce morbidity and mortality of this dangerous condition. Collaboration between psychiatry and other medical specialities may be the key to a successful outcome.
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Affiliation(s)
- Raj Velamoor
- Professor Psychiatry, Northern Ontario School of Medicine, Laurentian and Lakehead University, Ontario, Canada; Emeritus Professor Psychiatry, Schulich School of Medicine, Western University, Ontario, Canada.
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23
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Zhang F, Kanzali P, Rubin V, Paras C, Goldman J. Neuroleptic malignant syndrome with thyroid disorder: An unusual case report. Medicine (Baltimore) 2017; 96:e8191. [PMID: 28953679 PMCID: PMC5626322 DOI: 10.1097/md.0000000000008191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Neuroleptic malignant syndrome (NMS) is a life threatening neurologic emergency associated with neuroleptic or antipsychotic agent use. NMS is rarely related to thyroid disease. PATIENT CONCERNS We report a case of NMS in a 66-year-old male with past medical history of paranoid schizophrenia on chlorpromazine, diabetes, hypertension and asthma, who presented with a humeral fracture after a fall. Patient developed hyperpyrexia, altered consciousness, autonomic instability, elevated serum creatine kinase (CK) without rigidity. DIAGNOSES CT head and workup for infection were negative. Electroencephalogram (EEG) showed generalized slow wave activity. Ultrasound revealed a large goiter with nodules. INTERVENTIONS Chlorpromazine was stopped due to concern of NMS. Patient was treated with cooling, fluid and electrolyte maintenance. OUTCOMES Patient slowly improved and CK level normalized. Thyroid-stimulating hormone (TSH) level trended down from 10.2 mIU/L to 0.02 mIU/L. Patient was discharged with aripiprazole. LESSONS Hypothyroidism predisposes patients to NMS by altering central dopaminergic systems. The typical symptoms may be masked by hypothyroidism. Thyroid dysfunction should be excluded in all patients with NMS. Discontinuing antipsychotic agents decreases TSH levels which maybe due to the negative feedback of dopaminergic activity. This is the first case report describing dramatic changes in TSH after discontinuing chlorpromazine in NMS.
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Affiliation(s)
- Fan Zhang
- Department of Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn
| | - Parisa Kanzali
- Ross University School of Medicine, Portsmouth, Dominica
| | - Vadim Rubin
- Department of Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn
| | - Chris Paras
- Department of Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn
| | - Joel Goldman
- Division of Endocrinology, Brookdale University Hospital and Medical Center, Brooklyn, New York
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Malignant Catatonia Warrants Early Psychiatric-Critical Care Collaborative Management: Two Cases and Literature Review. Case Rep Crit Care 2017; 2017:1951965. [PMID: 28250995 PMCID: PMC5303832 DOI: 10.1155/2017/1951965] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/05/2017] [Indexed: 01/31/2023] Open
Abstract
Malignant catatonia (MC) is a life-threatening manifestation which can occur in the setting of an underlying neuropsychiatric syndrome or general medical illness and shares clinical and pathophysiological features and medical comorbidities with the Neuroleptic Malignant Syndrome (NMS). The subsequent diagnosis and definitive therapy of MC are typically delayed, which increases morbidity and mortality. We present two cases of MC and review recent literature of MC and NMS, illustrating factors which delay diagnosis and management. When clinical features suggest MC or NMS, we propose early critical care consultation and stabilization with collaborative psychiatric management.
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Oruch R, Pryme IF, Engelsen BA, Lund A. Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatr Dis Treat 2017; 13:161-175. [PMID: 28144147 PMCID: PMC5248946 DOI: 10.2147/ndt.s118438] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ramadhan Oruch
- Department of Pharmacology and Toxicology, School of Pharmacy, Benghazi University, Benghazi, Libya
| | | | | | - Anders Lund
- Department of Clinical Medicine, Section of Psychiatry, University of Bergen, Bergen, Norway
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26
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Drews JD, Christopher A, Evans DC. Neuroleptic malignant syndrome in the trauma intensive care unit: Diagnosis and management of a rare disease in a challenging population. Int J Crit Illn Inj Sci 2017; 7:119-121. [PMID: 28660166 PMCID: PMC5479074 DOI: 10.4103/ijciis.ijciis_100_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a life-threatening neurological disorder associated with the use of antipsychotic medications. Many of its classic signs, such as fever and altered mental status, are nonspecific in trauma intensive care unit (ICU) patients, and its rarity makes it a difficult diagnosis in this population. However, delays in treatment can be costly both in terms of hospital resources and patient outcomes. We herein report a case of a 54-year-old trauma patient with NMS precipitated by a combination of cocaine withdrawal and neuroleptic medications. Few cases of NMS in the intubated polytrauma patient have been described in the literature previously. Given the poor outcomes associated with this disorder, ICU patients would benefit from risk stratification and avoidance of neuroleptic medications in those at highest risk for NMS, particularly patients who are withdrawing from dopaminergic agents.
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Affiliation(s)
- Joseph David Drews
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University, OH, USA
| | - Andrew Christopher
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University, OH, USA
| | - David Clay Evans
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University, OH, USA
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27
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Kovacic S, Roginic S, Nemrava J, Gospocic K, Seferovic Saric M, Luetic K. Acute pancreatitis in two patients with Parkinson’s disease. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1312802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Sanja Kovacic
- Department of Neurology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
- Faculty of Medicine, University of Osijek, Josip Juraj Strosmayer, 31000 Osijek, Croatia
| | - Sinisa Roginic
- Department of Internal Medicine, General Hospital Zabok and Hospital of Croatian, Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Johann Nemrava
- Department of Surgery, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Ksenija Gospocic
- Department of Radiology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Maida Seferovic Saric
- Department of Neurology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Kresimir Luetic
- Clinic for Internal Medicine, University Hospital Sv. Duh, Sv. Duh 64, 10000 Zagreb, Croatia
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28
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Atypical Neuroleptic Malignant Syndrome Associated With Paliperidone Long-Acting Injection: A Case Report. J Clin Psychopharmacol 2016; 36:277-9. [PMID: 27043124 DOI: 10.1097/jcp.0000000000000507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Maligne hypertherme Syndrome auf der Intensivstation. Med Klin Intensivmed Notfmed 2016; 111:407-16. [DOI: 10.1007/s00063-016-0173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/08/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022]
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30
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Neuroleptic Malignant Syndrome: A Case Aimed at Raising Clinical Awareness. Case Rep Med 2015; 2015:769576. [PMID: 26170837 PMCID: PMC4480239 DOI: 10.1155/2015/769576] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 11/17/2022] Open
Abstract
A 60-year-old man with a history of bipolar disorder on risperidone, bupropion, and escitalopram was admitted for community acquired streptococcal pneumonia. Four days later, he developed persistent hyperthermia, dysautonomia, rigidity, hyporeflexia, and marked elevation of serum creatine phosphokinase. He was diagnosed with neuroleptic malignant syndrome (NMS) and improved with dantrolene, bromocriptine, and supportive therapy. This case emphasizes the importance of considering a broad differential diagnosis for fever in the ICU, carefully reviewing the medication list for all patients, and considering NMS in patients with fever and rigidity.
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31
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Gragnani A, Cezillo MVB, Oliveira AF, Ferreira LM. Neuroleptic malignant syndrome in trauma patient. Burns 2015; 41:1147-51. [PMID: 26048132 DOI: 10.1016/j.burns.2015.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/10/2014] [Accepted: 01/17/2015] [Indexed: 11/27/2022]
Abstract
In recent years, there has been an increased use of neuroleptic agents in the unit care in trauma patients. There is a lack of prospective data, and most of the information is obtained from related cases. It is needed to have a high index of suspicion with regard to excluding neuroleptic malignant syndrome (NMS) in patients taking neuroleptics and presenting with hyperthermia, because of the potentially fatal consequences. It is a rare syndrome in the burn patient with a lack of proven treatments, and high morbidity and mortality are related. In the actual literature there are few related cases of NMS in the polytrauma patient, particularly in association with psychiatric conditions. In burn NMS is a rare complication with difficult diagnosis, because of the similar symptoms that can occur either in patients in the Burn Unit Care with other fatal conditions that are present in the acute phase response. Actually, there is no marker for the NMS, which difficult the early diagnosis and prognosis. The treatment still is based on case reports, with lack of clinical trials, but remain as standard and universally accepted. Besides that, the neural signaling of the NMS indicates possibilities for better understanding of the pathophysiology treatment protocol.
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Affiliation(s)
- Alfredo Gragnani
- Division of Plastic Surgery, Federal University of São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Brazil.
| | | | - Andrea Fernandes Oliveira
- Burn Care Unit - Division of Plastic Surgery, Federal University of São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Brazil
| | - Lydia Masako Ferreira
- Chairwoman of Division of Plastic Surgery, Federal University of São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Brazil
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32
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Ross C. Successful clozapine rechallenge following clozapine-induced neuroleptic malignant syndrome. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.03.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Neuroleptic malignant syndrome (NMS) is a potential life-threatening adverse effect of antipsychotics. Characteristic signs and symptoms of NMS include hyperthermia, muscle rigidity, altered mental status, and autonomic instability. Treatment of NMS includes discontinuation of any antipsychotic or other potentially offending agents. This report describes the details of a patient diagnosed with NMS induced by clozapine with subsequent successful rechallenge. Given limited therapeutic options for patients with treatment-resistant schizophrenia, clinicians should be cognizant of potential risks but aware of the possibility of successful rechallenge with clozapine.
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33
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Hyperosmolar hyperglycemic state secondary to neuroleptic malignant syndrome. Am J Emerg Med 2015; 33:126.e1-2. [DOI: 10.1016/j.ajem.2014.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/03/2014] [Accepted: 06/03/2014] [Indexed: 11/19/2022] Open
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Patil BS, Subramanyam AA, Singh SL, Kamath RM. Low serum iron as a possible risk factor for neuroleptic malignant syndrome. Int J Appl Basic Med Res 2014; 4:117-8. [PMID: 25143888 PMCID: PMC4137635 DOI: 10.4103/2229-516x.136800] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 02/04/2014] [Indexed: 11/04/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a rare, but fatal condition characterized by rigidity, fever, dysautonomia and altered consciousness along with elevated serum creatinine phosphokinase levels and leukocytosis. Treatment of NMS includes symptomatic and specific treatment with drugs like bromocriptine may be given. Risk factors for NMS include dehydration, parenteral antipsychotics and high potency antipsychotics. One of the important, but lesser known risk factors for NMS is low serum iron. Pronounced reduction in serum iron suggests that acute phase reactants do have a role in NMS. The present case report focuses on the importance of low serum iron as a risk factor for NMS.
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Affiliation(s)
- Bhushan Subhash Patil
- Department of Psychiatry, TNMC and B.Y.L Nair Ch. Hospital, Mumbai, Maharashtra, India
| | - Alka A Subramanyam
- Department of Psychiatry, TNMC and B.Y.L Nair Ch. Hospital, Mumbai, Maharashtra, India
| | - Shipra L Singh
- Department of Psychiatry, TNMC and B.Y.L Nair Ch. Hospital, Mumbai, Maharashtra, India
| | - Ravindra M Kamath
- Department of Psychiatry, TNMC and B.Y.L Nair Ch. Hospital, Mumbai, Maharashtra, India
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35
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McCullough A, Stroup JS, Brahm N. A Case Report of Probable Neuroleptic Malignant Syndrome. J Pharm Technol 2013. [DOI: 10.1177/8755122513500917] [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 report a case of probable neuroleptic malignant syndrome (NMS) of unknown origin. Case Summary: A 32-year-old Caucasian man was found unconscious by emergency services. On presentation to the emergency department, he had a temperature of 107.5°F (41.9°C) and a Glasgow Coma Scale rating of 3 (range = 3-15). Fluids were administered and cooling blankets applied. He was admitted to the intensive care unit. Supportive measures decreased his temperature to 101.7°F (38.7°C). Arterial blood gas, comprehensive metabolic panel, complete blood count, and cardiac risk panel results were within normal limits; urinalysis and urine and serum drug screens were negative. He had been discharged on the following medications: benztropine, citalopram, chlorpromazine, divalproex, haloperidol, and hydroxyzine. Based on the medication discharge list and clinical presentation, the Naranjo Adverse Drug Reaction Probability Scale was applied. The criteria scoring indicated a probable relationship (8 of 12) between the medications prescribed and symptoms consistent with NMS. Discussion: NMS has been reported with antipsychotics (APs) and other medications with dopaminergic activity. The etiology is poorly understood. Risk factors (ie, recent initiation or dose increase of an AP, dehydration, or genetic susceptibility) may increase the potential. The differentiation between the diagnosis of NMS and other factors, such as serotonin syndrome or hyperthermia, includes laboratory and clinical presentation characteristics. The potential contributions of anticholinergic agents, psychiatric comorbidities, and other risk factors were identified for this patient. Conclusions: We report the case of a patient found unresponsive and comatose. A variety of assessment measures were used to identify potential causes. Based on evaluations, clinical presentation, the medication list, and criteria for an adverse drug event, a diagnosis of NMS was given. Health care providers may not be fully aware of the potential severity for this medication-related effect in patients with multiple risk factors.
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Affiliation(s)
| | - Jeffrey S. Stroup
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Nancy Brahm
- University of Oklahoma College of Pharmacy, Tulsa, OK, USA
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36
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Catatonia, neuroleptic malignant syndrome, and cotard syndrome in a 22-year-old woman: a case report. Case Rep Psychiatry 2013; 2013:452646. [PMID: 24093068 PMCID: PMC3777205 DOI: 10.1155/2013/452646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 08/07/2013] [Indexed: 11/24/2022] Open
Abstract
The following case study describes a 22-year-old woman with depression and symptoms of psychosis who developed neuroleptic malignant syndrome after using Risperidone, thus requiring life support equipment and Bromocriptine, later recovering after seven days. From a psychiatric and neurological point of view, however, the persistence of catatonic syndrome and Cotard syndrome delusions was observed, based on assertions such as “I do not have a heart,” “my heart is not beating,” “I can not breathe,” “I am breaking apart,” “I have no head” (ideas of negation) and statements about the patient being responsible for the “death of the whole world” (ideas of enormity). Brain NMR revealed leukoencephalopathy, interpreted as scar lesions caused by perinatal neurological damage, after discarding other pathologies. The patient responded well to electroconvulsive therapy after 11 sessions. Organic vulnerability to these syndromes, as well as their coexistence and clinical differentiation is discussed in the light of the data observed.
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37
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Abstract
Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are two rare, but serious adverse reactions associated with psychotropic medications. While the disorders may share certain features, there are differences in how they are managed and treated. This article reviews the risk factors, clinical presentation, and treatment of SS and NMS.
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38
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Auffret M, Béné J, Lachatre M, Lambert M, Gautier S. [Neuroleptic malignant syndrome in a patient treated with alimemazine]. Therapie 2013; 68:173-4. [PMID: 23886464 DOI: 10.2515/therapie/2013030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/20/2013] [Indexed: 11/20/2022]
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39
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Mogwitz S, Buse J, Ehrlich S, Roessner V. Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2013; 112:281-349. [PMID: 24295625 DOI: 10.1016/b978-0-12-411546-0.00010-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.
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Affiliation(s)
- Sabine Mogwitz
- Department of Child and Adolescent Psychiatry, University Medical Center, Technische Univerität Dresden, Dresden, Germany
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Abstract
The aim of this review is to provide information for interpreting outcome results from monitoring of antipsychotics in biological samples. A brief overview of the working mechanisms, pharmacological effects, drug interactions, and analytical methods of classical and atypical antipsychotics is given. Nineteen antipsychotics were selected based on their importance in the worldwide market as follows: amisulpride, aripiprazole, asenapine, bromperidol, clozapine, flupenthixol, haloperidol, iloperidone, lurasidone, olanzapine, paliperidone, perphenazine, pimozide, pipamperone, quetiapine, risperidone, sertindole, sulpiride, and zuclopenthixol. A straightforward relationship between administered dose, plasma or serum concentration, clinical outcome, or adverse effects is often lacking. Nowadays, focus lies on therapeutic drug monitoring and individualized therapy to find adequate treatment, to explain treatment failure or nonresponse, and to check patient compliance. However, extensive research in this field is still mandatory.
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Nama S, Aftab M. It's all atypical: can clozapine cause atypical neuroleptic malignant syndrome? Aust N Z J Psychiatry 2012; 46:280-1. [PMID: 22391291 DOI: 10.1177/0004867411433973] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sujay Nama
- Mental Health Unit, Bundaberg Base Hospital, Bundaberg, Australia
| | - Muhammad Aftab
- Mental Health Unit, Bundaberg Base Hospital, Bundaberg, Australia
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Molina D, Tingle LE, Lu X. Aripiprazole as the causative agent of neuroleptic malignant syndrome: a case report. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 9:148-50. [PMID: 17607339 PMCID: PMC1896300 DOI: 10.4088/pcc.v09n0211b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Jerrell JM, McIntyre RS, Tripathi A. Childhood treatment with psychotropic medication and development of comorbid medical conditions in adolescent-onset bipolar disorder. Hum Psychopharmacol 2011; 26:451-9. [PMID: 21898598 DOI: 10.1002/hup.1227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 07/12/2011] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study aims to investigate the association between early treatment with psychotropic medications and the development of medical comorbidities in pediatric patients who develop bipolar disorder (BD). METHODS Data from the South Carolina Medicaid program covering all medical services and medication prescriptions between January 1996 and December 2005 were used to determine the association between childhood exposure to psychotropic medications (i.e., psychostimulants, antidepressants, and antipsychotics) and the diagnosis of select comorbid medical conditions in 1841 children and adolescents diagnosed with Diagnostic and Statistical Manual IV defined BD. RESULTS In separate regressions controlling for all psychotropic medications prescribed and all comorbid medical conditions diagnosed prior to the BD, hypertension and cardiovascular disorders were more likely in those prescribed second generation antipsychotics or psychostimulants, whereas obesity/overweight was more likely in those taking serotonin norepinephrine reuptake inhibitor/heterocyclic antidepressants, and asthma was more likely in those taking selective serotonin reuptake inhibitors. CONCLUSION Childhood cardiometabolic events appear to be systematically associated with specific classes of psychotropic medications, but no innate, developmental sequencing of cardiometabolic abnormalities was apparent before early adolescence in patients subsequently diagnosed and treated for BD.
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Affiliation(s)
- Jeanette M Jerrell
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, South Carolina, USA.
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Affiliation(s)
- Shinji Yasugi
- Mirrabook Adult Psychiatry Inpatient Unit, Shellharbour, NSW, Australia
| | - Vikas Garg
- Mirrabook Adult Psychiatry Inpatient Unit, Shellharbour, NSW, Australia
| | - Greg Been
- Mirrabook Adult Psychiatry Inpatient Unit, Shellharbour, NSW, Australia
| | - Penny Magoulas
- Mirrabook Adult Psychiatry Inpatient Unit, Shellharbour, NSW, Australia
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Wong OF, Fung HT, Lam TSK. An Unusual Cause of Delirium in a Psychiatric Patient: Abrupt Clozapine Discontinuation. HONG KONG J EMERG ME 2010. [DOI: 10.1177/102490791001700210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rapid clinical deteriorations have been reported after abrupt discontinuation of clozapine. A 42-year-old psychiatric patient presented with ingestion of hand-disinfectant solutions causing transient impairment of his conscious level. His clozapine therapy was discontinued for a short period of time and he developed delirium with normal results of investigations for underlying organic causes. His delirium resolved rapidly after the reintroduction of clozapine. The withdrawal effects of abrupt discontinuation of clozapine are discussed in this article.
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Rock W, Elias M, Lev A, Saliba WR. Haloperidol-induced neuroleptic malignant syndrome complicated by hyperosmolar hyperglycemic state. Am J Emerg Med 2009; 27:1018.e1-3. [PMID: 19857430 DOI: 10.1016/j.ajem.2008.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Accepted: 12/07/2008] [Indexed: 11/19/2022] Open
Abstract
Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic emergency that may be caused by neuroleptic agents of any class. The association with hyperosmolar hyperglycemic state (HHS) is rare and carries a grave prognosis. We describe the case of a 25-year-old male patient with haloperidol-induced NMS complicated by HHS that culminated in the patient's death despite all treatment efforts. Physicians caring for diabetic psychiatric patients who are treated with neuroleptic agents should be aware of this association that may be prevented by tight glycemic control.
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Affiliation(s)
- Wasseem Rock
- Department of Internal Medicine C, Ha'emeK Medical Center, Afula, Affiliated to the Technion-Israel Institute of Technology, Faculty of Medicine, Haifa, Israel
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Jerrell JM. Neurological and cardiovascular adverse events associated with antimanic treatment in children and adolescents. CNS Neurosci Ther 2009; 16:25-31. [PMID: 19769597 DOI: 10.1111/j.1755-5949.2009.00087.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
To identify the factors associated with incident neurological and cardiovascular adverse events in children and adolescents treated with antimanic agents, a retrospective, longitudinal study was conducted. Medicaid medical and pharmacy claims between January 1996 and December 2005 were used to identify 3657 children and adolescents prescribed antimanic medications, and a random sample of 4500 children not treated with psychotropic medications. All adverse events examined (sedation/drowsiness, headaches, involuntary movements/extrapyramidal symptoms (EPS), cardiovascular events, hypertension, and orthostatic hypotension) were more prevalent in the antimanic-treated cohort. The odds of developing incident sedation/drowsiness and headaches were significantly higher for those prescribed carbamazepine, and co-prescribed selective serotonin reuptake inhibitors or antipsychotics. The odds of incident involuntary movements/EPS were significantly higher for those co-prescribed antimanic and antipsychotic agents, and those with comorbid central nervous system (CNS), organic brain disorders/mental retardation, or epilepsy. Incident cardiovascular events, hypertension, and orthostatic hypotension odds were significantly higher for those co-prescribed antimanic agents and antipsychotics, or those with comorbid epilepsy or metabolic conditions. Co-prescription of antimanic and antipsychotic agents is more likely associated with neurological and cardiovascular adverse reactions, especially in young patients with preexisting CNS/neurological disorders.
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Affiliation(s)
- Jeanette M Jerrell
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
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Ulger F, Dilek A, Karakaya D, Senel A, Sarihasan B. Fatal fever of unknown origin in acute cervical spinal cord injury: five cases. J Spinal Cord Med 2009; 32:343-8. [PMID: 19810636 PMCID: PMC2718819 DOI: 10.1080/10790268.2009.11760788] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Patients with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of autonomic dysfunction, including thermodysregulation. Thermoregulation is identified as an autonomic function, although the exact mechanisms of thermodysregulation have not been completely recognized. Quad fever is a hyperthermic thermoregulatory disorder that occurs in people with acute cervical and upper thoracic spinal cord injuries. First described in 1982, it has not been widely discussed in the literature. METHODS Case reports of 5 patients with cervical spinal cord injury (SCI). RESULTS Five of 18 patients (28%) with acute cervical SCI who were admitted during a 1-year period had fatal complications caused by persistent hyperthermia of unknown origin. CONCLUSIONS Patients with acute traumatic cervical and upper thoracic SCI are at risk for thermoregulatory dysfunction. Changes in the hypothalamic axis may be implicated, especially in the light of modification in hypothalamic afferent nerves, but this hypothesis has not yet been explored. Thermodysregulation may be an early sign of autonomic dysfunction. A comprehensive guideline is needed for the management of elevated body temperature in critically ill patients with cervical SCI, because this condition may be fatal.
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Affiliation(s)
- Fatma Ulger
- 1Department of Anesthesiology and Reanimation, 2Department of Neurosurgery Ondokuz Mayis University, Kurupelit, Samsun, Turkey
| | - Ahmet Dilek
- 1Department of Anesthesiology and Reanimation, 2Department of Neurosurgery Ondokuz Mayis University, Kurupelit, Samsun, Turkey
| | - Deniz Karakaya
- 1Department of Anesthesiology and Reanimation, 2Department of Neurosurgery Ondokuz Mayis University, Kurupelit, Samsun, Turkey
| | - Alparslan Senel
- 1Department of Anesthesiology and Reanimation, 2Department of Neurosurgery Ondokuz Mayis University, Kurupelit, Samsun, Turkey
| | - Binnur Sarihasan
- 1Department of Anesthesiology and Reanimation, 2Department of Neurosurgery Ondokuz Mayis University, Kurupelit, Samsun, Turkey
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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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