Neuroleptic Malignant Syndrome: Diagnostic Dilemma in the Medically Ill

Parsa, Mahmoud A.; Picken, Andrew; Keating, Robert F.

doi:10.29046/jjp.010.2.004

Cited by 3 publications

(4 citation statements)

References 8 publications

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“…Laboratory investigations that aids in the diagnosis of NMS include elevated serum CK activity, leucocytosis; deranged liver enzymes, myoglobinuria and electrolyte abnormalities which were present in this patient 6. Extraordinary levels of CK in NMS reflect massive rhabdomyolysis which precipitates renal failure and other sequelae of the illness that leads to mortality as seen in this case.…”

Section: Discussionmentioning

confidence: 62%

“…Extraordinary levels of CK in NMS reflect massive rhabdomyolysis which precipitates renal failure and other sequelae of the illness that leads to mortality as seen in this case. Studies have shown that plasma exchange coupled with continuous haemodiafiltration facilitates excretion of myoglobinuria thus increasing the survival rate of patients compared with that when haemodialysis alone is used 6 7…”

Section: Discussionmentioning

confidence: 99%

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Neuroleptic malignant syndrome masked by cerebral malaria

Muniandy

Sinnathamby

Sakthi³

2013

BMJ Case Reports

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SUMMARYA 38-year-old man with an underlying psychiatric illness presented with altered sensorium and abnormal behaviour. He was febrile at 38°C and weak looking; otherwise no other abnormalities were detected. A blood film conducted for malarial parasite (BFMP) revealed Plasmodium falciparum; hence a diagnosis of cerebral malaria was made. He was treated with antimalarial drugs for 2 days prior to being transferred out to the ward following clinical improvement. He subsequently developed episodes of stupor and refusal of feeding. Following an evaluation by the psychiatrist, a diagnosis of catatonic schizophrenia was made and he was started on oral sulpiride and benhexol. Unfortunately, he developed high-grade fever at 40°C with muscle rigidity and fasciculation. The diagnosis of neuroleptic malignant syndrome (NMS) was clinched and the antipsychotics were discontinued. However he succumbed to NMS several days later due to multiorgan failure. BACKGROUND

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Section: Discussionmentioning

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Neuroleptic malignant syndrome masked by cerebral malaria

Muniandy

Sinnathamby

Sakthi³

2013

BMJ Case Reports

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“…Eight articles were noncontrolled studies including data on TCP + TCA combination strategies, 16,38–44 3 were noncontrolled studies including data on TCP + lithium or another mood stabilizer, 38,45,46 13 were noncontrolled studies including data on TCP + antipsychotic (FGAs and second-generation antipsychotics [SGAs]) combination strategies, 38,47–58 1 study included data on TCP + benzodiazepine combination, 38 1 included data on TCP + thyroxine, 59 and 1 on TCP + stimulant 60 . Twelve articles were case reports or case series comprising TCP + SSRI/SNRI/serotonin precursor combination strategies, 17,61–71 9 on TCP + TCA combination strategies, 72–80 9 on TCP + lithium combination strategies, 81–89 4 on TCP + other mood stabilizer other than lithium combination strategies, 72,90–92 5 on TCP + antipsychotics (FGAs and SGAs) combination strategies, 93–97 3 on TCP + benzodiazepine combination strategies, 98–100 3 on TCP + (es-)ketamine combination strategies, 101–103 1 on TCP + thyroxine combination, 18 1 on TCP + disulfiram combination, 104 6 on TCP + stimulant combination strategies, 72,105–109 1 on TCP + N -acetylcysteine, 110 1 on TCP + pindolol, 111 and 1 on TCP + l -DOPA 112 . Please see the Tables 1 to 3 for a detailed description of the study characteristics, outcome, and safety parameters.…”

Section: Resultsmentioning

confidence: 99%

“…From the noncontrolled studies, 2 were rated as “2−” 40,43 and 27 as “3,” 15,16,38,39,41,42,44–60 whereas 1 study yielded data for 5 compound subgroups 38 . All case reports and case series were rated as “3.” 17,18,61–109,111,112 …”

Section: Resultsmentioning

confidence: 99%

60 Years of Combining Tranylcypromine

Wagner

Seemüller

Hasan

2022

J Clin Psychopharmacol

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Background: Tranylcypromine is the only irreversible monoamine oxidase inhibitor that is approved in the United States and in Europe for the management of treatment-resistant major depressive disorder. Comprehensive data in the literature regarding the efficacy and tolerability of tranylcypromine (TCP) combination strategies have not been systematically investigated yet. Methods:We conducted a systematic review of available literature based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study types considered eligible for inclusion were studies that reported information on efficacy and/or tolerability/ adverse effects of pharmacological TCP add-on or coadministration strategies among people with psychiatric disorders.Results: Ninety-six articles were included in qualitative analyses. A relevant body of evidence shows that TCP combined with first-and secondgeneration antipsychotics seems relatively safe and might have beneficial effects in some patients with depressive disorders, although caution is needed with some second-generation antipsychotics that have proserotonergic activity. Although evidence is not entirely consistent, amitriptyline as add-on agent might be efficacious and associated with a low rate of severe adverse events. Although available data from case reports are scarce, certain other agents, such as trazodone, but also lithium, seem to have a good riskbenefit profile with regard to TCP that should be further investigated in the context of high-quality studies.Conclusions: Any combination of a psychotropic with TCP should be preceded by an evaluation of drug-to-drug interaction and an informed consent process and followed by close monitoring. Before any combination strategy, doctors should reevaluate factors of pseudo-treatment resistance, such as rapid-metabolizing status, noncompliance, trauma, alternative diagnosis, or drug abuse.

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An Atypical Course of Neuroleptic Malignant Syndrome

Schneiderhan

Marken

1994

The Journal of Clinical Pharma

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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.

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Neuroleptic Malignant Syndrome: Diagnostic Dilemma in the Medically Ill

Cited by 3 publications

References 8 publications

Neuroleptic malignant syndrome masked by cerebral malaria

Neuroleptic malignant syndrome masked by cerebral malaria

60 Years of Combining Tranylcypromine

An Atypical Course of Neuroleptic Malignant Syndrome

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