Treatment of Neuroleptic Malignant Syndrome with Electroconvulsive Therapy in an Adolescent with Psychosis.

Abstract

[Author Affiliation]Canan Tanidir. Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Sena Aksoy. Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Ozge Canbek. Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Gizem Funda Aras. Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Ali Guven Kilicoglu. Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Ayten Erdogan. Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Address correspondence to: Canan Tanidir, MD, Department of Child and Adolescent Psychiatry, Bakirkoy State and Research Hospital for Neurological Disorders and Mental Health, 34140, Istanbul, Turkey, E-mail: canantanidir@yahoo.comTo the Editor:Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic complication associated with the use of neuroleptic agents, and is characterized by fever, rigidity, autonomic nervous system dysfunction, mental status change, mutism, leukocytosis, and elevated creatine kinase. NMS can occur after the use of any atypical antipsychotic including clozapine (Erol et al. 2013).Many patients with NMS improve spontaneously with the cessation of the neuroleptic, or respond to treatment with a dopamine agonist and a muscle relaxant. A proportion of patients show an incomplete response and should receive a course of electroconvulsive therapy (ECT). The case reports suggest that ECT is effective in the treatment of NMS (Hermesh et al. 1987), and the response to ECT appears to be faster than that to drugs, although no direct comparison exists (Trollor and Sachdev 1999). In a recent review, Luchini et al. stated that ECT should be considered as first-line treatment in patients with malignant catatonia and NMS, and, in general, in all catatonic patients who are refractory or partially responsive to benzodiazepines, and early intervention with ECT is encouraged to avoid undue deterioration of the patient's medical condition (Luchini et al. 2015). ECT may be a suitable alternative to neuroleptics in patients who are psychotic and have developed NMS. In addition, ECT may be a good choice because it may be difficult to differentiate NMS from lethal catatonia, and the life-saving role of ECT in the treatment of lethal catatonia is well described (Trollor and Sachdev 1999). However, there are unrealistic fears regarding ECT in adolescents.Here, we report on an adolescent referred for psychotic symptoms who developed NMS after treatment with olanzapine, haloperidol, and quetiapine, who was then treated successfully with ECT.Case ReportAB was a 17-year-old girl who was referred to an adult psychiatry clinic by her family because of her paranoid delusions. Her family said that for the last month, the girl had been afraid of going to school, claiming that someone was following her and that everyone in the school was malicious. She did not want to eat her meals because she thought they were poisoned. She insisted that someone had made changes to the identity cards of all family members. She was hospitalized with a diagnosis of acute psychosis in a psychiatry unit and olanzapine i.m. 20 mg/day was started. After 6 days, because of her hostile behavior, 15 mg/day i.m. haloperidol and 7.5 mg/day lorazepam were added to olanzapine. Three weeks later, the patient was transferred to our child and adolescent inpatient unit because of treatment resistance. …