Neuroleptic Rechallenge after Neuroleptic Malignant Syndrome: Case Report and Literature Review

Abstract

Neuroleptic malignant syndrome (NMS) is associated with essentially all of the currently available antipsychotic agents. The signs and symptoms associated with the syndrome are hyperpyrexia, defined by body temperature > 38°C; extreme muscle rigidity, with or without elevated creatine Phosphokinase or hyperreflexia; and other symptoms such as altered level of consciousness and/or autonomic dysfunction as manifested by labile blood pressure, tachycardia, tachypnea, urinary or fecal incontinence, pallor, or diaphoresis. This potentially fatal syndrome complicates the treatment of patients with recurrent psychotic symptoms because of the possibility for recurrence of the NMS. A case of recurrent NMS is presented in which the patient was rechallenged with an antipsychotic agent. In addition, 41 reported cases of antipsychotic rechallenge after NMS are reviewed. The results of the review suggest that neuroleptic rechallenge following NMS is associated with an acceptable risk of recurrence in most patients. However, close monitoring for NMS and careful selection of patients for antipsychotic rechallenge is mandatory. A minimal time period of five days before rechallenge may also reduce the risk of recurrent NMS. Recurrence was not associated with patient age or gender, nor the antipsychotic agent used.

Neuroleptic Malignant Syndrome: Three Adolescents with Complicated Courses

“…There are numerous reports of successful neuroleptic rechallenge following NMS in adults (Wells et al 1988, Keck et al 1991, Sakkas et al 1991a). Recurrence rates during rechallenge are not well established, but may be as high as 30% (Hunter 1989).…”

Neuroleptic Malignant Syndrome

“…These patients present a challenge to the treating clinician, in that recurrence of NMS is a continued risk. Wells and colleagues reported that the risk of reoccurrence of NMS diminishes if at least 5 days had elapsed from recovery from NMS to neuroleptic rechallenge [125]. Rosebush and colleagues recommend a waiting period of 2 weeks between NMS recovery and neuroleptic rechallenge [126].…”

Multiple episodes of NMS: overlap with malignant catatonia

“…• Catatonia is a result of massive dopamine blockade due to excessive hyperstimulation in psychotic illness, whilst NMS is caused by a similar blockade but triggered by neuroleptics 12 18 However, it has also been reported that as many as 87% may be successfully rechallenged with an antipsychotic following an episode of NMS. 2 A longer washout period has been found to increase the likelihood of success of rechallenge.…”

“…2 A longer washout period has been found to increase the likelihood of success of rechallenge. 2,18 In one study of patients with a history of NMS, six out of nine patients were successfully treated with clozapine without any further complications. 19 …”