Diagnostic and therapeutic challenges in neuroleptic malignant syndrome: a severe medical case

Neuroleptic malignant syndrome (NMS) is a rare, idiosyncratic medical emergency usually associated with the use of dopamine antagonists, commonly typical antipsychotic drugs. However, it has been observed that it can occur with atypical antipsychotics as well. NMS is characterized by altered consciousness, fever, rigidity, autonomic instability and high creatine phosphokinase (CPK) blood levels. Here, we report a case of a 44-year-old female patient with history of a treatment-resistant bipolar disorder. She was admitted to our psychiatric ward for severe psychomotor agitation and treated with a therapy based on typical and atypical antipsychotics. During the course of the hospitalization she developed NMS. In this case, the diagnosis was delayed due to the slow and insidious symptom presentation, therefore requiring a differential diagnosis. Autoimmune NMDA receptor encephalitis, catatonic syndrome and malignant catatonia have been excluded. The patient met all the DSM-5 criteria for NMS: exposure to dopamine-blocking agent, severe muscle rigidity, fever, diaphoresis, dysphagia, altered level of consciousness, mutism, tremors, tachycardia, high or labile blood pressure, leukocytosis, high creatine phosphokinase. Since robust evidence-based protocols are lacking, here we discuss the relevance of this case in order to highlight the hurdles of a prompt diagnosis, clinical management of associated complications and treatment possibilities for such emergency.

Neuroactive Steroids in Responders and Nonresponders to Sleep Deprivation

Evidence from preclinical and clinical studies indicates that concentrations of neuroactive steroids are altered in depression and normalize after antidepressant pharmacotherapy. However, data on the impact of sleep deprivation on concentrations of neuroactive steroids are not available. Therefore, 29 drug-free patients (12 men, 17 women) with major depression according to DSM-IV criteria were treated with partial sleep deprivation (PSD). Response to PSD was defined as a reduction of at least 30% according to the 6-item version of the Hamilton Depression Scale (6-HAMD). Plasma samples were taken the day before and the day after PSD (day 0 and 1) and after one night of recovery sleep (day 2) at 8:00 am. Samples were quantified for neuroactive steroids by means of a highly sensitive and specific combined gas chromatography/mass spectrometry analysis. PSD did not influence concentrations of neuroactive steroids in either PSD responders (n = 20) or nonresponders (n = 9). However, nonresponders showed significantly higher concentrations of 3alpha,5alpha-tetrahydroprogesterone, 3alpha,5beta-tetrahydroprogesterone, and dehydroepiandrosterone before or after PSD compared to responders. In contrast to antidepressant drugs which correct the dysequilibrium of neuroactive steroids in major depression within several weeks, PSD does not affect the concentrations of neuroactive steroids in either responders or nonresponders.