Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome

Abstract

The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2016 O 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2015.10.042 Selected Topics: Psychiatric Emergencies PSYCHIATRIC EMERGENCIES FOR CLINICIANS: EMERGENCY DEPARTMENT MANAGEMENT OF NEUROLEPTIC MALIGNANT SYNDROME Michael P. Wilson, MD , PHD ,*† Gary M. Vilke, MD ,*† Stephen R. Hayden, MD ,* and Kimberly Nordstrom, MD , JD ‡§ *University of California at San Diego Medical Center, San Diego, California, †Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Laboratory, University of California San Diego, San Diego, California, ‡Denver Health Medical Center, Department of Behavioral Health, Psychiatric Emergency Service, Denver, Colorado, and §University of Colorado Denver, School of Medicine, Aurora, Colorado Reprint Address: Michael P. Wilson, MD , PHD , Department of Emergency Medicine, University of California at San Diego Medical Center, 200 West Arbor Drive, Mail Code #8676, San Diego, CA, 92103 , Keywords—altered mental status; neuroleptic malig- nant syndrome; dystonia; catatonia; rigidity What Do You Think is Going on with This Patient? The clinical presentation suggests neuroleptic malignant syndrome (NMS). Although first described more than 50 years ago, the diagnosis of NMS is primarily clinical (1). CLINICAL SCENARIO A 25-year-old man presents with a recent diagnosis of schizophrenia. He was discharged 1 week earlier from an inpatient psychiatric unit. His mother states that he has been acting ‘‘differently’’ for the past 2 days. He has not been ‘‘making any sense,’’ has felt warm to the touch, and today has been stiff and moving rigidly like a ‘‘robot.’’ The review of systems per his mother is nega- tive for hallucinations since leaving the hospital and is also negative otherwise, including for symptoms of infec- tion. On observing the patient, he is sitting quietly with minimal movements, marked diaphoresis, and a notice- able tremor. On physical examination, vital signs are tem- perature of 38.7 C (101.7 F), heart rate of 125 beats/min, blood pressure 168/102 mm Hg, respiratory rate 26 breaths/min, and oxygen saturation 98%. The patient is nonverbal to questioning and appears catatonic. He has generalized muscle rigidity, but no lateralizing neuro- logic findings. A lumbar puncture reveals no cells or organisms in the cerebrospinal fluid. What Key Findings Lead to the Diagnosis? Clues to an NMS diagnosis include a recent diagnosis of a psychotic disorder and inpatient psychiatric hospitaliza- tion. This information, along with a careful medication history, would suggest that the patient has been recently, or is potentially, aggressive. He is started on an antipsy- chotic medication. Other important features include pyrexia, extrapyramidal symptoms such as rigidity, and an altered level of consciousness (2). The time course also provides important information in this case. NMS typically develops within 24 to 72 h after starting the offending medication (3). The majority of cases of NMS develop symptoms within the first week, and virtu- ally all develop symptoms within the first 30 days (1). The type of antipsychotic may be less helpful for diagnosis. NMS is more common after high-potency, first-genera- tion antipsychotics (FGAs) like haloperidol, although it R ECEIVED : 10 October 2015; A CCEPTED : 21 October 2015