Abstract
We report a 29-year-old, HIV-positive woman being treated with antipsychotic medication for psychosis (Clopixol 200mg intramuscularly monthly, Risperidone 2mg orally daily Haloperidol 2.5mg twice a day), who presented with neuroleptic malignant syndrome. She was also receiving lorazepam and sodium valproate. The patient was referred to our department as she had developed involuntary upper limb movements and simple permanent focal seizure on the lower part of the left hemiface. Clinically the patient had altered consciousness, autonomic dysfunction, and rigidity. Her blood tests showed elevated creatine kinase (1467U/L) but no leucocytosis. We did a thorough workup for other causes of such a presentation. A comprehensive history was taken from the family to exclude other medications used. Her cerebrospinal fluid results were average. Blood tests did not show evidence of infection or other abnormalities. Computed tomography brain was normal. The patient died a few days after the beginning of the attack, which we have also observed in other HIV-female patients. As far as we know, it is the first report about this comorbidity reported in the medical literature.
Highlights
Most authors define neuroleptic malignant syndrome (NMS) as a rare, yet life-threatening, idiosyncratic reaction to medications, mostly but not limited to neuroleptic drugs[1,2,3]
One study conducted in 1986 discovered about 500 patients who were on neuroleptics, and about 1.4% clinically had NMS, while one case was fatal since it was not found in time[1]
Despite the following list being the most expected clinical presentation, as presented by the literature, none are specific to NMS11,13: elevated white cell count; metabolic acidosis as shown by arterial blood gas and urea/ electrolytes; elevated creatine kinase (CK); elevated serum muscle enzymes, e.g. lactic acid dehydrogenase and transaminases; elevated serum catecholamines, e.g. aldolase; and decreased serum iron levels
Summary
Most authors define neuroleptic malignant syndrome (NMS) as a rare, yet life-threatening, idiosyncratic reaction to medications, mostly but not limited to neuroleptic drugs (dopamine receptor antagonists)[1,2,3]. The patient was admitted to the Neurology Outpatient Department due to altered mental status, permanent partial simple myoclonic seizure on the left lower hemiface, and involuntary upper limb movement. On examination, her blood pressure was labile (ranging from 129/79mmHg to –158/112 mm Hg), and she had tachycardia (119 beats/minute) and mild dehydration. On the second day of admission, when were unaware of her previous treatments (especially the neuroleptics), the patient presented a temperature of 40.5°C Based on her clinical picture and follow-up with the family by social workers on her previous medications, the diagnosis of NMS was made. No post-mortem examination was conducted due to wishes of the family
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