Neuroleptic malignant syndrome due to risperidone misdiagnosed as status epilepticus

Neuroleptic malignant syndrome in children and adolescents: Systematic review of case reports

INTRODUCTION

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal drug adverse reaction. There are still few studies of this entity in the child-adolescent population.

OBJECTIVES

Describe the clinical, laboratory and therapeutic characteristics of children and adolescent patients with NMS. Analyse the grouping of symptoms present in NMS in the same population.

MATERIAL AND METHODS

A MEDLINE/PubMed search of all reported cases of NMS from January 2000 to November 2018 was performed and demographic, clinical, laboratory and therapeutic variables were identified. A factorial analysis of the symptoms was performed.

RESULTS

57 patients (42 males and 15 females) were included, (mean age 13.65 ± 3.89 years). The onset of NMS occurred at 11.25 ± 20.27 days with typical antipsychotics and at 13.69 ± 22.43 days with atypical antipsychotics. The most common symptoms were muscle stiffness (84.2%), autonomic instability (84.2%) and fever (78.9). The most common laboratory findings were CPK elevation and leucocytosis (42.1%). The most used treatment was benzodiazepines (28.1%). In the exploratory factorial analysis of the symptoms we found 3 factors: 1) "Catatonic" with mutism (0.912), negativism (0.825) and waxy flexibility (0.522); 2) "Extrapyramidal" with altered gait (0.860), involuntary abnormal movements (0.605), muscle stiffness (0.534) and sialorrhoea (0.430); and 3) "Autonomic instability" with fever (0.798), impaired consciousness (0.795) and autonomic instability (0.387).

CONCLUSIONS

NMS in children and adolescents could be of 3 types: catatonic, extrapyramidal and autonomic unstable.

Neuroleptic Malignant Syndrome in Children and Adolescents: Systematic Review of Case Reports

INTRODUCTION

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal drug adverse reaction. There are still few studies of this entity in the child-adolescent population.

OBJECTIVES

Describe the clinical, laboratory and therapeutic characteristics of children and adolescent patients with NMS. Analyse the grouping of symptoms present in NMS in the same population.

MATERIAL AND METHODS

A MEDLINE/PubMed search of all reported cases of NMS from January 2000 to November 2018 was performed and demographic, clinical, laboratory and therapeutic variables were identified. A factorial analysis of the symptoms was performed.

RESULTS

57 patients (42 males and 15 females) were included, (mean age 13.65±3.89 years). The onset of NMS occurred at 11.25±20.27 days with typical antipsychotics and at 13.69±22.43 days with atypical antipsychotics. The most common symptoms were muscle stiffness (84.2%), autonomic instability (84.2%) and fever (78.9). The most common laboratory findings were CPK elevation and leucocytosis (42.1%). The most used treatment was benzodiazepines (28.1%). In the exploratory factorial analysis of the symptoms we found 3factors: 1) "Catatonic" with mutism (0.912), negativism (0.825) and waxy flexibility (0.522); 2) "Extrapyramidal" with altered gait (0.860), involuntary abnormal movements (0.605), muscle stiffness (0.534) and sialorrhoea (0.430); and 3) "Autonomic instability" with fever (0.798), impaired consciousness (0.795) and autonomic instability (0.387).

CONCLUSIONS

NMS in children and adolescents could be of 3types: catatonic, extrapyramidal and autonomic unstable.

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.

Neuroleptic Malignant Syndrome Associated with Lithium Toxicity

Neuroleptic Malignant Syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction to neuroleptic drugs. Lithium is a first-line mood stabilizer used in the treatment and prophylaxis of bipolar disorder. There are several case reports of lithium-associated NMS, but only when it was given in combination with antipsychotics. Therefore, the possibility of NMS being secondary to the antipsychotics could not be ruled out in those cases. Here we present a case of lithium-induced NMS in a patient who was not being treated concomitantly with any other agent known to cause NMS. The patient, a 74-year-old female with a 30-year history of bipolar affective disorder, was admitted to the emergency room of the All India Institute of Medical Sciences, New Delhi, with history of high fever and generalized weakness for 10 days before the admission. NMS was established based the presence of three cardinal symptoms. She was started on intravenous fluids to correct her sodium levels slowly and requested to follow-up at the psychiatry clinic.