A Case of Neuroleptic Malignant Syndrome in a Profoundly Intellectually Disabled Patient with Successful Reintroduction of Antipsychotic Therapy with Quetiapine

Abstract

Neuroleptic Malignant Syndrome (NMS) is a rare condition clinically characterized by muscle rigidity, hyperthermia, autonomic instability, and acute mental status change. NMS is most often associated with use of high-potency first-generation antipsychotic medications; though, other neuroleptics have been implicated as well. NMS can be fatal with estimated mortality rates as high as 20%. Patients experiencing certain severe complications, including renal failure, have been associated with mortality as high as 50%, stressing the need for early recognition and treatment. Here we present the case of a 54-year-old male that initially presented with symptoms suspicious for sepsis, but who eventually developed a clinical picture consistent with NMS. We describe the diagnostic and treatment process leading to symptom remission. We then discuss our decision to reintroduce an atypical antipsychotic agent, quetiapine. This case illustrates the importance of early recognition of the signs and symptoms of NMS and the need to initiate treatment promptly in order to prevent complications, including death. This case also highlights the decision to resume antipsychotic pharmacotherapy after adequate resolution of NMS, demonstrating that it can be done so safely if started at low doses coupled with intensive monitoring of the patient.

Ziprasidone Associated Neuroleptic Malignant Syndrome

“…To our knowledge, this is one of only a few case reports of NMS presenting as a sepsis mimic. 3 Our case highlighted the need for increased study into the potential role of multiple receptors in NMS as well as the need for a high index of suspicion for those patients who present with SIRS, encephalopathy, and rigidity while on psychotropic medications.…”

“…1 As such, case reports continue to be a main source of information for clinicians. 3 Many of the signs of NMS are non-specific and qualify the patients for the systemic inflammatory response syndrome (SIRS). Our patient was transferred from an outside behavioral health facility due to worsening encephalopathy and SIRS thought to be secondary to sepsis.…”

“…While most patients fully recover and mortality rates have been decreasing due to early recognition and treatment, fatality rates are estimated between 5 -10%. [1][2][3] This case demonstrated how NMS can present as a mimic of sepsis or serotonin syndrome.…”

“…1 While incidence is estimated to be 0.02% 1 generally and 0.2% 2 among neuroleptic users, NMS continues to be an unpredictable and potentially life-threatening condition of which case reports continue to be a main source of information for clinicians. 3 Despite the advent of second-generation antipsychotics (SGA), NMS continues to be a rare yet severe adverse reaction to neuroleptics. 4 It is seen most often with abrupt cessation, decrease, or increase in dopaminergic dose.…”