Abstract

Sir, The neuroleptic malignant syndrome (NMS) is an important side effect of neuroleptic drugs. Fever, severe muscle rigidity and autonomic changes are considered its fundamental signs [1]. I have recently seen a case of NMS with some unusual features. A 40 year old male with a 4 year history of delusional disorder (DSM-III-R), had been treated with intramuscular injections of long-acting haloperidol decanoate for 2 years, at the dose of 150 mg once monthly. He had a mild resting tremor but no other parkinsonian signs. At the end of 1988 he was admitted to the Internal Medicine Department of Forli Hospital with a 7 day history of high fever (up to 40~ coarse shaking tremor and sweating. His family doctor had treated him with intramuscular injections of an antibiotic for some days, before sending him to the hospital. When I examined the patient as consultation liaison psychiatrist the day following admission, he displayed a continuous, coarse shaking tremor, affecting the entire body and impairing gait, along with sweating and fever (38.5~ There was no rigidity and his consciousness, blood pressure and heart rate were normal Laboratory tests performed on the same day showed increased levels of creatine phosphokinase (210 U / liter), ALT (95 U/liter) and AST (40 U/liter). An extensive clinical and laboratory evaluation revealed no abnormalities apart from those described above. As there was no evident cause for the fever I made the diagnosis of neuroleptic malignant syndrome and I started treatment with bromocriptine and orphenadrine. Two weeks later fever had disappeared but tremor, albeit reduced, was still present. My diagnosis was NMS because of the association of elevated temperature (in the absence of other systemic illness) and severe tremor. Several points are worth noting. First: rigidity, which is considered a fundamental sign for the diagnosis of NMS [1, 2[, was absent. Second: the clinical picture resolved despite the presence of a long-acting neuroleptic and it was never life-threatening. For this reason this case could be classified as a mild variant of NMS [1,3[. Third: contrary to previous reports [1, 2], in this case the NMS did not appear early in the course of neuroleptic treatment, but after two years of treatment. This case suggests that severe tremor should be considered a fundamental sign for the diagnosis of NMS, while the absence or rigidity should not preclude it. Further, the case supports the spectrum concept of the NMS [3].

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