The clinical presentations of neuroleptic malignant syndrome (NMS) and malignant catatonia (MC) are similar, posing a diagnostic challenge. Here, we present a 58-year-old Caucasian male who presented to the emergency department with an altered mental state, fever, tachycardia, and rigidity. Labs were remarkable for elevated creatine phosphokinase (CPK) and leukocytosis. The patient was on a regimen of clozapine and cariprazine to manage schizophrenia, lorazepam to treat catatonia, and mirtazapine to treat insomnia and appetite stimulation. The patient was initially diagnosed with NMS after common metabolic, infectious, and substance-induced etiologies were ruled out. Within 72 hours of receiving dantrolene and lorazepam, the patient's fever, tachycardia, and other laboratory abnormalities resolved. However, when the patient's rigidity, waxy flexibility, mutism, and stupor persisted, the diagnosis was reconsidered and changed to MC. Our case discusses the overlapping clinical presentations of NMS and MC, demonstrating a diagnostic challenge.
Adderall is one of the most commonly prescribed stimulant medications for attention deficit hyperactivity disorder (ADHD). Although safe and effective when clinically indicated at the appropriate dose, stimulant misuse may lead to serious adverse effects. We report a 29-year-old male with a diagnosis of ADHD who took more than the recommended therapeutic dose of Adderall prescribed by his psychiatrist. He subsequently presented with persistent psychotic symptoms, which responded to oral haloperidol. Due to treatment noncompliance with multiple recurring psychiatric hospitalizations, long-acting injectable haloperidol decanoate was considered to improve compliance and prognosis. The patient's psychosis remained in remission while on the long-acting injectable. In this case study, we highlight the need for future research to identify stimulant misuse risk factors. Randomized clinical trials are needed to determine the effectiveness of long-acting injectable antipsychotic medication in the management of persistent psychosis secondary to stimulant misuse.
Few existing cases of closed-eye visual hallucinations have been reported. These rare perceptual disturbances are distinct from open-eye visual hallucinations, as observed in Charles Bonnet syndrome. This case report discusses a 35-year-old male who presented with closed-eye visual hallucinations 24 hours before severe alcohol withdrawal. On initial presentation, the patient denied auditory or visual hallucinations. The day before the onset of severe alcohol withdrawal, the patient reported vivid, colorful, and lifelike visual hallucinations with his eyes closed which disappeared with eyes open. The hallucinations consisted of cartoon characters such as Daffy Duck, a lifelike blond woman with curly hair, and a tree-covered landscape. The patient endorsed awareness that the hallucinations were not real. The next day, the patient became acutely delirious with rapid onset of agitation, space-time disorientation, open-eye visual hallucinations, and emotionally disturbing illusions. The patient was promptly transferred to the intensive care unit (ICU) to manage severe alcohol withdrawal, including administration of intravenous sedation. During follow-up evaluation, the patient retained a clear memory of the closed-eye hallucinations. However, he had no recollection of the ICU course. Several etiologies were considered, including alcohol withdrawal complicated by polysubstance withdrawal and acute hepatitis, which resolved following pharmacological treatment. To the best of our knowledge, this is the first case report of its kind. Additional research is required to elucidate the etiology, mechanism, and clinical implications of closed-eye visual hallucinations.
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