Use of Intravenous Valproate in a Patient With Neuroleptic Malignant Syndrome

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Back to table of contents Previous article Next article LetterFull AccessUse of Intravenous Valproate in a Patient With Neuroleptic Malignant SyndromeRahul R. Tadke, M.D., DNB, and Praveen Suryavanshi, MBBS, DPMRahul R. TadkeSearch for more papers by this author, M.D., DNB, and Praveen SuryavanshiSearch for more papers by this author, MBBS, DPMPublished Online:1 Feb 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail SIR: A 22-year-old woman was admitted through casualty, with a history of altered behavior for approximately 15 days and history of fever, rigidity, tremors, and one episode of incontinence for a few days. The patient had autonomic disturbances, was partly oriented to time and place, and general condition was moderate.History given by a close relative about cheerfulness, excessive talkativeness, singing songs, reduced need for sleep, and grandiose ideation for approximately 2 weeks indicated an episode of mania. The patient received an injection of haloperidol intramuscularly to control the behavior a few days before, prior to the onset of new symptoms.A clinical diagnosis of neuroleptic malignant syndrome (NMS) was made, although other differentials of delirium due to general medical condition, including meningitis, were also considered.Baseline investigations were within normal limits, and total leukocytes count of 9000/cmm and the CSF study was inconclusive. Serum creatinine phosphokinase (CPK) levels were 3850 U/liter, suggestive of N.M.S. and this confirmed the diagnosis.Injection valproate was administered intravenously 250 mg on the first day and then 250 mg 12 hourly from the next day. A clonazepam tablet was also administered when needed. The following day, dramatic improvement in this patient, was observed. She was well oriented to time, place and person, and the rigidity had markedly reduced. Tremors were minimal, and there was no fever. After 6 days, the patient had minimal rigidity and mild tremors. There were no behavioral disturbances barring mild euphoria.Repeat serum CPK levels after 10 days was 30 U/liter (well within normal limits) and other baseline investigations were within normal limits. The patient was later switched to oral sodium valproate, and there were no features of NMS. The serum valproate level was 87 mcg/ml after 2 weeks.Intravenous valproate has been used for catatonia.1 In this isolated case (by chance), intravenous valproate was found to be effective in the symptoms of NMS.2,3There was no fear of the reemergence of psychotic features, which is common with bromocriptine. The strict monitoring as required for bromocriptine was also not needed. It serves a dual purpose for controlling manic features in patients of bipolar disorder.4 Even a substitute novel (atypical) antipsychotic (although less) carries the risk of NMS.Panjabrao Deshmukh Medical College , Department of Psychiatry, Amravati , Maharashtra, IndiaReferences1 Kruger S, Braunig P: Intravenous valproic acid in the treatment of severe catatonia J Neuropsychiatry Clin Neurosci. 2001; 13(2):303-304Google Scholar2 Lauterbach EC: Valproate for catatonia: need for caution in patients on SSRIs and antipsychotics.: J Neuropsychiatry Clin Neurosci. 2002;14(1):84-86Google Scholar3 Spehlmann R, Norcross K, Rasmus SC, et al: Improvement of stiff-man syndrome with sodium valproate. Neurology. 1981; 31(9):1162-113Google Scholar4 Grunze H, Erfurth A, Amann B, et al: Intravenous valproate loading in acutely manic and depressed bipolar I patients. J Clin Psychopharmacol 1999; 19(4):303–309Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByNeuroleptic Malignant Syndrome19 July 2016 | Annals of Pharmacotherapy, Vol. 50, No. 11Comment: Neuroleptic Malignant Syndrome Versus Serotonin Syndrome: The Search for a Diagnostic Tool13 March 2012 | Annals of Pharmacotherapy, Vol. 46, No. 4Neuroleptic Malignant Syndrome Following Levomepromazine DiscontinuationHisashi TaniiM.D., Ph.D.,Keiichi SakaM.D.,Ken InoueM.D., Ph.D.,Motohiro OkadaM.D., Ph.D.,1 April 2010 | The Journal of Neuropsychiatry and Clinical Neurosciences, Vol. 22, No. 2 Volume 18Issue 1 February 2006Pages 131-132 Metrics PDF download History Published online 1 February 2006 Published in print 1 February 2006