On the early recognition of neuroleptic malignant syndrome

Neuroleptic Malignant Syndrome After the Use of Venlafaxine in a Patient with Generalized Anxiety Disorder

Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse reaction to neuroleptics, which is characterized by hyperthermia, extrapyramidal symptoms, altered consciousness and autonomic dysfunction. Although NMS is most commonly induced by the high-potency neuroleptics, its development has also been associated with the use of non-neuroleptic agents that block central dopamine pathways. A 68-year-old man with generalized anxiety disorder and depressive symptoms presented at the emergency department (ED) with high fever, tremor, muscle rigidity, rhabdomyolysis and altered mental status. NMS was considered to have been caused by the recent addition and subsequent dose increase in his treatment regimen of venlafaxine, a serotonin norepinephrine reuptake inhibitor. He was successfully treated with bromocriptine, lorazepam, and fluid hydration in the ED and intensive care unit.

Atypical neuroleptic malignant syndrome caused by olanzapine

OBJECTIVE

Neuroleptic malignant syndrome (NMS) is a rare syndrome with four main symptoms: rigidity, hyperthermia, altered mental status and autonomic instability. We report a patient with an atypical manifestation of NMS.

METHOD

A single case was reported.

RESULTS

A patient with pneumonia developed delirium and was treated with olanzapine and developed a NMS with fluctuating hyperthermia and autonomic instability during a month. Only slight rigidity was present. Creatine kinase was not elevated. The patient was severely agitated and manic. After discontinuation of olanzapine the patient showed no psychopathology or hyperthermia.

CONCLUSION

NMS should be considered when patients treated with antipsychotics develop one or more symptoms of NMS.

Reinstitution of neuroleptic treatment with molindone in a patient with a history of neuroleptic malignant syndrome

The decision to reinstitute neuroleptic treatment in patients with a history of neuroleptic treatment is fraught with hazards. A case is reported in which neuroleptic treatment was successfully reintroduced with molindone after previous bouts of neuroleptic malignant syndrome (NMS) with trifluoperazine and thioridazine. Molindone may represent an alternative neuroleptic to consider in patients with a history of NMS, although all neuroleptics including clozapine and molindone may potentially precipitate this syndrome.

Neuroleptic rechallenge after neuroleptic malignant syndrome: case report and literature review

Neuroleptic malignant syndrome (NMS) is associated with essentially all of the currently available antipsychotic agents. The signs and symptoms associated with the syndrome are hyperpyrexia, defined by body temperature greater than 38 degrees C; extreme muscle rigidity, with or without elevated creatine phosphokinase or hyperreflexia; and other symptoms such as altered level of consciousness and/or autonomic dysfunction as manifested by labile blood pressure, tachycardia, tachypnea, urinary or fecal incontinence, pallor, or diaphoresis. This potentially fatal syndrome complicates the treatment of patients with recurrent psychotic symptoms because of the possibility for recurrence of the NMS. A case of recurrent NMS is presented in which the patient was rechallenged with an antipsychotic agent. In addition, 41 reported cases of antipsychotic rechallenge after NMS are reviewed. The results of the review suggest that neuroleptic rechallenge following NMS is associated with an acceptable risk of recurrence in most patients. However, close monitoring for NMS and careful selection of patients for antipsychotic rechallenge is mandatory. A minimal time period of five days before rechallenge may also reduce the risk of recurrent NMS. Recurrence was not associated with patient age or gender, nor the antipsychotic agent used.

Aetiology and treatment of neuroleptic malignant syndrome

The clinical triad of fever, movement disorder, and altered mentation known as NMS represents an infrequent yet highly lethal side effect of neuroleptic therapy. Although awareness and recognition are on the rise, underdiagnosis of the disorder may represent a neglected clinical problem of major proportions considering the number of patients treated with neuroleptics. The recognition of problems such as NMS and tardive dyskinesia point out the need for investigation of low-dose efficacy and neuroleptic serum levels. The idea that neuroleptics are free of severe side effects has created a clinical fallacy that high doses of high potency neuroleptics should be administered to acutely psychotic patients and that low doses of neuroleptics may be used for various diagnostic entities. The emphasis on NMS and its 20% mortality rate should point out that neuroleptics should only be used when clinically indicated to treat psychosis and should be given in the lowest possible dose that achieves antipsychotic effects. Although treatment strategies are still being formulated, aggressive medical care and specific drug therapies exist to reverse the symptoms of this syndrome. With proper education, psychiatrists and other specialists can recognize and treat NMS effectively and thus prevent its malignant outcome.