An Atypical Course of Neuroleptic Malignant Syndrome

Abstract

Based on the discussion of NMS, certain conclusions may be reached in regard to this patient. In the psychiatric setting, agitation and confusion alone are not suggestive of NMS. However in this patient, the symptoms of agitation, the rapid development of EPS symptoms unresponsive to anticholinergic therapy, autonomic changes (tachycardia, diaphoresis, and incontinence), and elevated CPK, met most of the diagnostic criteria described in Table VI. However, this case may have described an atypical presentation of NMS because of the absence of temperature increases during the onset of symptoms and the 7-week hospitalization for NMS. The patient's later onset of temperature elevations was a result of an aspiration pneumonia. Pneumonia and renal failure significantly increased the morbidity and extended the course of the illness. As a result, the diagnosis and specific treatment of NMS were delayed because of atypical symptoms and complications. In this patient, treatment of NMS with bromocriptine did not start until 10 days into hospitalization. A delay in pharmacologic therapy in this patient may have contributed to persistence of symptoms. The patient showed signs of improvement on day 21 during combination bromocriptine, benztropine, and dantrolene therapy. Moreover, this case exemplifies the rigorous need for supportive therapy and adjunctive pharmacologic therapy for primary and secondary complications resulting from NMS. In conclusion, because of the wide range of risk factors and variations of NMS, a systematic approach to diagnosing and treating NMS is critical to a successful outcome. Discontinuation of antipsychotics, maintenance of supportive therapy aimed at preventing dehydration, hemodynamic, and electrolyte imbalances, and pharmacotherapy are essential in the treatment of NMS.

A case of tetrabenazine‐induced neuroleptic malignant syndrome after prolonged treatment

“…This case emphasizes the importance of considering the diagnosis of NMS in psychiatric patients who are taking tetrabenazine and other dopamine receptor-blocking agents and then show a change in mental status, includmg signs of psychosis. Mental status changes, such as mutism, catatonia, stupor, coma, and agitation, have been reported to be a common clinical presentation of this syndrome, whereas delusional thinking and paranoia, as seen in our patient, are not considered common (2,12). The early agitation, hallucinations, and delusional thinking observed in our patient initially suggested a primary psychiatric illness.…”

“…Therefore, the pathogenesis underlying this syndrome is likely to be more complex. Other mechanisms that have been proposed involve prostaglandins, calcium, iron, or neurotransmitters, such as catecholamines, gamma-aminobutyric acid, and excitatory amino acids (glutamate) (12,(14)(15)(16)(17)(18).…”

“…It has been proposed that the clinical similarities between NMS and serotonin syndrome may be explained by a common underlying neurochemical change ( 1 9,23,24). For example, clinical reports have associated a number of drugs (phenelzine, fluoxetine, lithium, and 3,4-methylenedioxymethamphetamine) with both the serotonin syndrome and the neuroleptic malignant syndrome (12,14,19,20,(22)(23)(24)(25). The confusion between these two syndromes may be due to the close association between the dopaminergic and serotonergic systems in the central nervous system (CNS).…”

Atypical Neuroleptic Malignant Syndrome Associated with Use of Clozapine

“…However, we emphasize the absence of hyperthermia, since its maximum temperature registered was 37.3°C, fever being one of the typical criteria found in this syndrome [24] considering it as an atypical variant [25]. …”

Neuroleptic Malignant Syndrome

“…In the management of neuroleptic malignant syndrome the most effective measures include prompt recognition, withdrawal of neuroleptic medication, and transfer to an intensive care unit, with attention to hydration, fever reduction, sedation with benzodiazepines-if indicated-and control of rigidity with bromocriptine or dantrolene. The adjunctive use of bromocriptine has been reported to reduce the duration of the neuroleptic malignant syndrome episode and the risk of mortality'8 20 44; similar claims have been made for dantrolene, which may also have a central action in addition to its effects on calcium transmission in the sarcoplasmic reticulum." 's Based on current evidence, these agents should be instituted in most cases of neuroleptic malignant syndrome.…”