Atypical neuroleptic malignant syndrome in adolescence

Abstract

Objective To report re-challenges of antipsychotic drugs after neuroleptic malignant syndrome (NMS) in a case of Cotard syndrome and considering electroconvulsive treatment as an option in these cases. Case report A 17-year-old adolescent, treated for acute psychotic attack with multi-antipsychotic (olanzapine, risperidone) for 15 days, developed NMS within 48hours of the addition of low doses of clozapine to his regimen. Symptoms included fever, agitation, dysautonomia, pulmonary edema, ventricular failure and laboratory findings, which included elevation of CK levels, leukocytes, transaminase, resolved after discontinuation of psychotropics, supportive management and 6 days of treatment with bromocriptine and amantadine. At first, patient was treated with low doses of quetiapine. Then, we decided to imply ECT because of two reasons. The first reason is low dosage of quetiapine was not believed to control symptoms which included Cotard syndrome based on assertions such as I am dead, I cannot breathe, My teeth and my bones are melted, suicidal thoughts, incoherence speech. The second reason is increasing quetiapine dose rapidly could have caused relapsing of NMS. Finally, we transferred our patient to another child psychiatry clinic where ECT can be applied. Discussion Starting atypical antipsychotic drugs in re-emergence of post NMS psychosis and catatonia is a challenge. Because of the risk of relapsing NMS, anti-psychotic drugs must be started lower dosage, titrated up slowly then patient should be monitored at least two weeks until resumption of therapy. Process of monitoring depends on existing of clinical residua. Moreover, it is unclear when clinical residua exist, thus it is difficult to interpret the existing guidelines on safe reintroduction of antipsychotics. At that point, ECT can be considered as an option in order to control psychotic symptoms. Conclusions Clinicians should closely monitor patients when restarting anti-psychotic drugs after NMS owing to risk of relapsing NMS and ECT should be considered as an option in order to control symptoms.