Neuroleptic Malignant Syndrome Research Articles

Neuroleptic malignant syndrome presenting without hyperthermia: A case report of an atypical presentation

Neuroleptic malignant syndrome presenting without hyperthermia: A case report of an atypical presentation

Use of En-Bloc Multiple Monitored Electroconvulsive Therapy in Benzodiazepine Refractory Malignant Catatonia.

We report a case of an adolescent female experiencing benzodiazepine and single-stimulation electroconvulsive (ECT)-refractory malignant catatonia, who improved with the use multiple monitored ECT (mmECT). Per the 2001 American Psychiatric Association guidelines, mmECT should be considered only in cases of intractable seizures or neuroleptic malignant syndrome. Since 2001, neuroleptic malignant syndrome and malignant catatonia have been described as occurring along the same spectrum of illness. Therefore, given the life-threatening nature of her condition, as well as the brief seizure duration she experienced from single-stimulation ECT, the patient was treated with en-bloc and 2-stimulation mmECT. The patient demonstrated a significant improvement in response to this treatment, with her Bush-Francis Catatonia Rating Scale score decreasing by 89%. At 2-year follow-up in an outpatient neurodevelopmental catatonia clinic, the patient has been able to return to school in her previous advanced placement classes and has not required maintenance ECT.

Atypical Antipsychotics and Lithium Induced Neuroleptic Malignant Syndrome associated with Acute Kidney Injury: A Case Report

Neuroleptic Malignant Syndrome (NMS) is a rare but serious adverse reaction to antipsychotic medications. This case report presents a 56-year-old male with bipolar disorder on a regimen of Olanzapine, Clozapine and Lithium carbonate, who developed typical NMS. He had muscle rigidity, hyperthermia, rhabdomyolysis which led to acute kidney injury. Prompt withdrawal of psychotropic medications and administration of supportive therapies was done, yet the patient's condition deteriorated, leading to Multiple Organ Dysfunction Syndrome (MODS) and eventually mortality. This case shows the complexity of managing NMS in the context of polypharmacy emphasizing the need for vigilance when prescribing antipsychotic combinations and the challenges faced in treating NMS, especially when there are associated complications.

Neuroleptic malignant syndrome in puerperal women

Introduction Neuroleptic malignant syndrome is an rare event, even more so among patient from puerperal period. The incidence risk is of 0.11%. It is often occurs when a patient is prescribed on antipsychotic for long duration of time. Case Report We report a case of a female patient, two weeks in post natal period presented with altered behaviour at home. She has prior admission being treated for post partum psychosis with anti psychotic. However antipschotic was withheld as she developed extrapyramidal symptoms while in ward. At home, she developed fever, altered sensorium and fitting-like-episode. On arrival patient was unresponsive and with features of impaired airway patency. Her had unstable vital sign with elevated blood pressure, heart rate and temperature. Brain imagine came back normal, excluding brain pathology. She was diagnosed as neuroleptic malignant syndrome as fulfilled features of elevated creatine kinase. She was treated symptomatic by providing first aid to reduce temperature and started on benzodiazepines. She was subsequently admitted to intensive ward and responded well to treatment Conclusion Physician must be familiar and have high index of suspicious to identify and treat neuroleptic malignant syndrome. Without prompt treatment, it is highly fatal.

Successful Treatment of Both Refractory Neuroleptic Malignant Syndrome and Subsequent Catatonia With Electroconvulsive Therapy in a Patient With Suspected Kufs Disease.

We describe a patient suffering from probable Kufs disease who developed a neuroleptic malignant syndrome (NMS) after use of an antipsychotic agent over some weeks during hospitalization due to neuropsychiatric symptoms. Transferred to the neurology department, the patient quickly developed catatonic features. She did not respond to usual medical treatment but did respond to electroconvulsive therapy (ECT). The patient worsened following a nosocomial SARS-CoV-2 infection but improved again during a second course of ECT. We discuss Kufs disease as a potential risk factor for NMS and address the link between NMS and catatonia as well as the indication for ECT in both disorders. We also discuss the impact of SARS-CoV-2 infection on the clinical outcome. We describe the long recovery process and the secondary worsening of the patient on a cognitive level.

Neuroleptic malignant syndrome and serotonin syndrome: a comparative bibliometric analysis

ObjectiveThis study aimed to analyze and map scientific literature on Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) from prestigious, internationally indexed journals. The objective was to identify key topics, impactful articles, prominent journals, research output, growth patterns, hotspots, and leading countries in the field, providing valuable insights for scholars, medical students, and international funding agencies.MethodsA systematic search strategy was implemented in the PubMed MeSH database using specific keywords for NMS and SS. The search was conducted in the Scopus database, renowned for its extensive coverage of scholarly publications. Inclusion criteria comprised articles published from 1950 to December 31st, 2022, restricted to journal research and review articles written in English. Data were analyzed using Microsoft Excel for descriptive analysis, and VOSviewer was employed for bibliometric mapping.ResultsThe search yielded 1150 articles on NMS and 587 on SS, with the majority being case reports. Growth patterns revealed a surge in NMS research between 1981 and 1991, while SS research increased notably between 1993 and 1997. Active countries and journals differed between NMS and SS, with psychiatry journals predominating for NMS and pharmacology/toxicology journals for SS. Authorship analysis indicated higher multi-authored articles for NMS. Top impactful articles focused on review articles and pathogenic mechanisms. Research hotspots included antipsychotics and catatonia for NMS, while SS highlighted drug interactions and specific medications like linezolid and tramadol.ConclusionsNMS and SS represent rare but life-threatening conditions, requiring detailed clinical and scientific understanding. Differential diagnosis and management necessitate caution in prescribing medications affecting central serotonin or dopamine systems, with awareness of potential drug interactions. International diagnostic tools and genetic screening tests may aid in safe diagnosis and prevention. Reporting rare cases and utilizing bibliometric analysis enhance knowledge dissemination and research exploration in the field of rare drug-induced medical conditions.

Dual Toxidrome of Anti-cholinergic Storm and Neuroleptic Malignant Syndrome: A Therapeutic Challenge Overcome by Intrathecal Neostigmine

Anticholinergic toxicity and neuroleptic malignant syndrome (NMS) are common toxidromes in medical emergencies. However, their co-occurrence, resulting in a dual toxidrome, is rare and presents significant diagnostic and therapeutic challenges. We present the case of a 23-year-old young male with polysubstance dependence, admitted following combined trihexyphenidyl and risperidone toxicity. He was diagnosed with a dual toxidrome of anticholinergic storm and NMS. Treatment of NMS included lorazepam and bromocriptine. Due to the unavailability of physostigmine, the preferred antidote for anticholinergic syndrome, intrathecal neostigmine was administered. The patient subsequently recovered and was discharged. This case highlights the complexity of managing dual toxidromes and the need for alternative therapeutic strategies in resource-limited settings.

Clozapine abrupt cessation fueling overlap neuroleptic malignant syndrome and serotonin syndrome with oculomotor dysfunction: a case report

Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) are life-threatening conditions caused by adverse reactions to neuroleptics and antidepressant medications. The overlap of both syndromes is rare but has been described previously. Differentiating between both entities based on the clinical presentation can be difficult. We present a case of a young male patient with history of schizophrenia, admitted to the Medical Intensive Care Unit (MICU) for septic shock, who developed NMS and SS with oculomotor dysfunction following the abrupt cessation of clozapine while still being on an antidepressant.

Neuroleptic Malignant Syndrome - review of pathophysiology, clinical presentation, differentiation and management

Introduction and purpose: The number of invented and produced medications has increased over recent years. Besides their positive impact on health, they invariably provide various kinds of side effects. This review is focused on malignant neuroleptic syndrome, a rare condition with no fully confirmed pathogenesis, which at least partially can be explained as an adverse effect of blocking dopamine receptors. Even though it usually affects psychiatric or neurological patients, doctors of all medical specializations should stay alert, as the condition can often lead to premature death. Brief description of knowledge: The main symptoms associated with NMS are hypertonia, hyperpyrexia, autonomic instability and altered consciousness. They can appear in any configuration, sometimes followed by less characteristic manifestations. It should be primarily differentiated from serotonin syndrome, malignant hyperpyrexia and catatonia, mostly through the interview of those who have taken medications and undergone surgeries, as there are not any specific lab tests available. Fundamental treatment methods consist of neuroleptic withdrawal, intensive supportive care, drug administration and eventually ECT. Summary: NMS is an uncommon, severe disease that should be carefully considered in patients treated with neuroleptics. Due to its rarity and sudden onset, it appears to be problematic to conduct widespread research and studies, so there are still no concrete, consistent and unquestioned guidelines on recognizing and treating the condition.

Aripiprazole-induced quasi-neuroleptic malignant syndrome: two case reports

BackgroundSignificant elevation of creatine kinase levels (above three digits) and leucocytosis in the absence of muscle rigidity, tremors, or autonomic dysfunction can pose a real challenge in the context of antipsychotic treatment as an early herald of neuroleptic malignant syndrome.Case presentationWe present here two cases of adult male patients of Black British heritage, ages 51 years and 28 years, respectively. Both received a diagnosis of schizoaffective disorder and presented with massive increase of creatine kinase blood level after aripiprazole depot administration, one with pernicious increase associated with silent neuroleptic malignant syndrome, and the second with asymptomatic benign enzyme elevation.ConclusionThough aripiprazole use is less likely to cause neuroleptic malignant syndrome, on rare occasions it can produce massive symptomatic or asymptomatic increase in serum creatine kinase enzyme levels, raising the need for close monitoring, especially at the initial doses of the drug.

Acute Disseminated Encephalomyelitis (ADEM) Presenting as Neuroleptic Malignant Syndrome (NMS) (P7-14.017)

Acute Disseminated Encephalomyelitis (ADEM) Presenting as Neuroleptic Malignant Syndrome (NMS) (P7-14.017)

Disentangling the Diagnoses of Psychotic Depression, Catatonia, Neurocognitive Disorders, and Delirium: A Multidisciplinary Approach

An ambiguous clinical presentation can create diagnostic uncertainty, leading to delays in effective interventions and increasing the likelihood of adverse clinical outcomes. Unfortunately, many psychiatric conditions share overlapping clinical symptoms. Psychotic depression, catatonia, neurocognitive disorders, and delirium are all examples of distinct clinical conditions with overlapping symptomatology, and all require decidedly different therapeutic interventions. While much literature is devoted to the diagnostic criteria and management of these clinical conditions, little is dedicated to the challenge of disentangling these diagnoses when faced with a complex clinical presentation.We present here a complicated psychiatric inpatient hospitalization of a 77-year-old male who exemplified this diagnostic challenge. He primarily presented with severely depressed mood and decreased functionality, remaining in bed for much of the day with little attention to basic hygiene and oral intake. While records from a recent outside hospitalization carried a historical diagnosis of catatonia, his moderate level of engagement with providers and somatic delusion of disseminated prostate cancer suggested an alternate diagnosis of psychotic depression. However, before a diagnostic conclusion could be reached, other clinical characteristics surfaced. Following a singular administration of olanzapine shortly after his initial assessment, he developed Lilliputian hallucinations, prominent parkinsonism, and significantly altered mentation.Neuroleptic sensitivity raised clinical suspicion for an underlying neurocognitive disorder such as dementia with Lewy bodies, and a consult was placed to the neuropsychology service. While dementia could not be fully ruled out, they did recommend additional workup to rule out herpes simplex encephalitis, autoimmune limbic encephalitis, and paraneoplastic syndromes. After his MRI imaging revealed moderate microvascular ischemic changes, a true multidisciplinary approach to care was taken, as neurology was consulted to also help narrow the differential. An EEG was unremarkable and a serum encephalitis panel was also unremarkable. Olanzapine was discontinued with significant improvement in parkinsonism and cognition; however, severe neurovegetative symptoms and somatic and nihilistic delusions persisted. While antipsychotics remained clinically indicated for a suspected depression with psychotic features, caution was taken due to established neuroleptic sensitivity, subtle catatonic features, and the related risks of neuroleptic malignant syndrome. Ultimately, low-dose quetiapine was initiated with some benefit; however, he continued to remain acutely depressed and withdrawn with prominent negativism. Trials with benzodiazepines for these catatonic features were also approached with caution to avoid potential risks of delirium.Over time, a multidisciplinary approach to psychopharmacologic interventions and medication trials led the team to a principal diagnosis of major depressive disorder with psychotic features and subtle catatonia. The abrupt changes observed early in the hospital course were determined to be related to olanzapine-induced anticholinergic delirium. With greater diagnostic certainty, the team was able to counsel the patient and family about the importance of pursuing electroconvulsive therapy (ECT). The patient's cardiovascular risk factors and known microvascular changes were considered in the determination of the appropriateness for ECT. After starting ECT, he was immediately noted to have objective improvement, and following his fifth treatment, he was deemed appropriate for discharge after exhibiting significant improvement in depression and functionality and reporting near-resolution of somatic delusions. He was able to complete ECT on an outpatient basis and follow-up visits note durable improvements in mood, functionality, and quality of life, continuing to enjoy an active lifestyle of socializing with family and playing tennis. We use this case to further explore the clinical challenges that stem from the symptomatic similarity between psychotic depression, catatonia, neurocognitive disorders, and delirium and discuss optimal therapeutic approaches when the presentation appears complex and equivocal.

Macroglossia Revealing a Neuroleptic Malignant Syndrome: a Clinical Images

Neuroleptic malignant syndrome is a rare and potentially fatal side effect that can occur in response to treatment with antipsychotic drugs. It is characterized by four main symptoms: Impaired mental function, fever, muscle rigidity and autonomic dysfunction. We report the case of a 20-year-old patient, followed for psychosis, in whom a new therapeutic line was adapted 3 days ago: Largactil (chlorpromazine) and Haldol (Haloperidol), who presented to the maxillofacial emergency department with tongue laceration. Clinical examination revealed in an agitated, uncooperative tachycardic and apyretic patient, revealed a generalized muscular spasm associated with trismus attacks, causing tongue injuries due to the installed macroglossia.

Antipsychotic-associated neuroleptic malignant syndrome (NMS) in schizophrenia patients: a narrative review

Neuroleptic malignant syndrome (NMS) is a neurological disorder with an high mortality rate among schizophrenia patients who receive antipsychotics as the primary long-term therapy. Appropriate selection of antipsychotics in NMS should be carefully considered to obtain maximal effectiveness with minimal side effects. An evaluation of the safety profile of the antipsychotics is important due to their different treatment patterns and rapid onset of symptoms. This review article aimed to compare the safety profile of antipsychotics in relation to NMS in schizophrenia patients. It was a narrative review using multiple search engines included PubMed, Google Scholar, and Springer to collect publications from 2007 to 2023. Of the total 14 articles reviewed, 7 articles explained the role of antipsychotics in NMS, 5 articles about the onset of NMS, and 7 articles about mortality rate. The incidence of NMS was less then 0.11%, typical antipsychotics were the most common cause of NMS, especially high-potency antipsychotics compared with atypical antipsychotics. Meanwhile, the onset of NMS consistently occured within 30 d of antipsychotic initiation with a symptom duration of 1 to 30 d, and the mortality rate was also higher for typical antipsychotics. In conclusion, the choice of antipsychotics must be carefully considered and its use must be monitored due to the rapid onset and high mortality. The use of antipsychotics is not free from the risk of NMS. The heterogeneous symptoms of NMS require earlier detection to reduce disease progression.

Neuroleptic malignant syndrome: a neuro-psychiatric emergency

Characterised by fever, altered mental status, muscle rigidity and autonomic dysfunction, neuroleptic malignant syndrome is a life-threatening idiosyncratic reaction to antipsychotic medication; around one in 10 cases end in cardiac arrest. The primary cause of neuroleptic malignant syndrome is dopamine receptor blockade, and the standard causative agent is an antipsychotic drug. While first-generation (typical) neuroleptics such as haloperidol, fluphenazine, trifluoperazine and prochlorperazine pose the greatest risk, neuroleptic malignant syndrome has been reported with second-generation (atypical) neuroleptics such as risperidone, clozapine, olanzapine and ziprasidone. Paramedic awareness of neuroleptic malignant syndrome as a neuropsychiatric emergency is paramount to reducing serious morbidity and even death in patients presenting with symptoms and a history of antipsychotic use. Treatment is individualised and based on clinical presentation, with supportive medical therapy being a key intervention.

First generation antipsychotic-associated serious adverse events in women: a retrospective analysis of a pharmacovigilance database.

Women have been under-represented in trials of antipsychotic medications. Our primary objective was toevaluate five adverse events (AE) associated with first-generation antipsychotics (FGAs) among women relative to menthrough an analysis of the FDA Adverse Event Reporting System (FAERS). We queried 24.6 million AE reports from 2000 to 2023 involving FGAs. The study cohort consisted of chlorpromazine (n = 3317), fluphenazine (n = 1124), haloperidol (n = 16,709), loxapine (n = 3151), perphenazine (n = 816), thioridazine (n = 665), thiothixene (n = 244), and trifluoperazine (n = 360). Cases of neuroleptic malignant syndrome (NMS), tardive dyskinesia (TD), Torsades de Pointes (TdP), agranulocytosis (AG), and cerebrovascular adverse events (CVAE) were identified. Reporting odds ratios (ROR) and associated 95% confidence intervals (CI) were calculated with logistic regression for each AE among women relative to men. A total of 2,857 serious AEs were evaluated in the study cohort (NMS = 1810, TD = 434, TdP = 260, AG = 149, CVAE = 204). The ROR for women compared to men was 0.79 (95% CI, 0.71-0.87) for NMS, 0.83 (0.68-1.01) for TD, 1.21 (0.94-1.53) for TdP, 0.71 (0.51-0.98) for AG, and 0.91 (0.68-1.19) for CVAE. A secondary analysis revealed a higher odds in women compared to men of hospitalization associated with reports of TD (ROR = 1.95, 1.29-2.94) and death associated with reports of AG (ROR = 2.46, 1.15-5.24). A subgroup analysis of haloperidol revealed an ROR = 1.67 (1.26-2.21) for women relative to men for TdP. The subgroup analysis of haloperidol AEs revealed a significantly higher reporting odds ratio for TdP. Additionally, the secondary study findings suggest that women were more vulnerable to worse outcomes associated with certain AEs of FGAs.

An afebrile neuroleptic malignant syndrome with hyponatremia: A case report.

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening situation in response to the adverse reaction of antipsychotic medications characterized by high-grade fever, altered Glasgow coma scale, autonomic dysfunction, and stiffness. We herein present a case with a typical presentation of stiffness and autonomic dysregulations along with the atypical symptoms of urinary incontinence and a history of falls. The patient was afebrile with hyponatremia, showing a similar presentation diagnosed as NMS and treated successfully according to the hospital protocol.

Atypical antipsychotic-induced neuroleptic malignant syndrome

The rare neuroleptic malignant syndrome (NMS) is associated with early mortality of >30%. Better supportive care has reduced mortality to <10%. Atypical antipsychotics such as clozapine and risperidone are associated with an atypical but potentially lethal, NMS. A 22-year-old male developed NMS after being treated with clozapine and risperidone for aggression associated with mental retardation for about 8 years. For the past 1 year, the dose of clozapine was 200 mg/day and the dose of risperidone was 8 mg/day. The patient presented with symptoms of hyperthermia, perspiration, neck rigidity, and tonic posturing of all four limbs with tongue bite and frothing from the mouth. On examination, the patient’s Glasgow coma Scale was E3V1M4. He was intubated and given antibiotics, antiepileptic, tablet bromocriptine 2.5 mg (1-1-1-1), and other supportive treatment. The patient showed improvement in 10 days. Knowledge of diagnostic features, risk factors, treatment modalities, and differential diagnosis of NMS is essential. Early diagnosis and prompt treatment can reduce mortality and morbidity significantly.

Neuroleptic Malignant Syndrome with haloperidol in a patient with alcohol withdrawal delirium

Neuroleptic Malignant Syndrome with haloperidol in a patient with alcohol withdrawal delirium

Neuroleptic malignant syndrome following clozapine withdrawal

Neuroleptic malignant syndrome following clozapine withdrawal