Treatment Of Neuroleptic Malignant Syndrome Research Articles

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.

Management of a trauma patient with alcohol withdrawal who developed neuroleptic malignant syndrome in Korea: a case report

Neuroleptic malignant syndrome (NMS) is a rare but fatal condition, with a high mortality rate. NMS is characterized by altered mental status, fever, myoclonus, autonomic dysfunctions, and elevated creatinine phosphokinase. The clinical manifestations may be confused with alcohol-related symptoms, trauma, sepsis, postoperative agitation, or malignant hyperthermia. A 69-year-old male patient with alcohol withdrawal was admitted to the operating theatre to rule out septic shock due to mesenteric injury after multiple trauma. He was suspected NMS with abrupt increase body temperature to 41.7°C after haloperidol administration. Active cooling and rapid fluid infusion was done during anesthesia. Delayed diagnosis and treatment of NMS lead to catastrophic result. Therefore, if the patient's past medical history is unknown or clinical symptoms develop that are suggestive of NMS, early treatment must be considered.

Multidisciplinary collaboration in diagnosis and treatment of neuroleptic malignant syndrome complicated with pneumonia: report of three cases

BackgroundNeuroleptic malignant syndrome (NMS) is a relatively rare and a potentially fatal syndrome. It is a serious complication associated with antipsychotic therapy. NMS is easily prone to pneumonia, rhabdomyolysis and other problems. However, the clinical features of NMS complicated with pneumonia remains largely unclear.Case presentationHere, we described three female adult patients of NMS complicated with pneumonia in our own hospital. The symptoms of the patients were controlled with antipsychotic drugs at admission. Symptoms such as high fever, high muscle tone, difficulty in eating, phlegm in the throat, anhelation, rhabdomyolysis and autonomic nervous dysfunction occurred 2 days after the treatment, which mainly concentrated within 1 week. In addition, they are all healed.ConclusionsNMS is a rare and serious complication in psychiatric department, which is easy to be complicated with pneumonia and respiratory failure. Timely identification and early intervention could help achieve a good prognosis.

Клинический случай успешного лечения злокачественного нейролептического синдрома на фоне острой токсико-аллергической реакции IV степени

Злокачественный нейролептический синдром является потенциально опасным осложнением при проведении нейролептической терапии, требующим своевременной диагностики, основанной на исключении других причин гипертермии, и специфических лабораторных исследований. Тактика лечения данного состояния принципиально отличается от тактики ведения больных с другой патологией, сопровождающейся гипертермией. В статье представлен клинический случай успешной и своевременной диагностики и лечения данного состояния.

Dexmedetomidine Infusion as a Novel Supportive Therapy for Fluphenazine-Induced Neuroleptic Malignant Syndrome in a 10-Year-Old Boy: A Case Report and Review of Literature

AbstractA 10-year-old male child patient developed symptoms of neuroleptic malignant syndrome (NMS) 1 month following initiation of fluphenazine for behavioral therapeutic management. Dexmedetomidine infusion was able to adequately control the symptoms of NMS with resolution of encephalopathy. This was the first report of novel dexmedetomidine utilization for the treatment of NMS. We suggest using dexmedetomidine as an adjunctive agent to control NMS symptomatology without attendant risk of respiratory depression.

Hyperthermia, Fever, and Fever of Undetermined Origin

Abnormal elevation of body temperature, or pyrexia, can occur in one of two ways: hyperthermia or fever. In hyperthermia, thermal control mechanisms fail, so that heat production exceeds heat dissipation. In contrast, in fever, the hypothalamic thermal set point rises, and intact thermal control mechanisms are brought into play to bring body temperature up to the new set point. The distinction between fever and hyperthermia is more than academic: hyperthermia is best treated with drugs that lower the thermal set point, such as aspirin, other cyclooxygenase inhibitors, or acetaminophen. Fever of undetermined origin (FUO) presents one of the most challenging and perplexing problems in clinical medicine. Such fevers may persist for weeks or months in the absence of characteristic clinical findings or clues. Ultimately, most such obscure fevers prove to be caused by common diseases presenting in an atypical fashion rather than by rare and exotic illnesses. This chapter discusses fever and hyperthermia and further clarifies the distinction between fever and hyperthermia. The section on hyperthermia discusses the etiology of hyperthermia; the epidemiology, pathophysiology, diagnosis, differential diagnosis, treatment, and prevention of heatstroke; and the diagnosis and treatment of neuroleptic malignant syndrome, serotonin syndrome, and malignant hyperthermia of anesthesia. The section on fever discusses the pathogenesis, diagnosis, and treatment of fever, as well as the possible benefits and complications of elevated body temperature. The section on FUO presents the defining criteria of FUO; the etiologic classification of FUO, including the infections and neoplasms possibly responsible; and the diagnosis of FUO, including laboratory and radiologic studies, biopsies, and the role of exploratory laparotomy. Tables describe the causes of hyperthermia; the causes of FUO as reported in various studies over five decades; and a comprehensive list of causes of FUO. An algorithm depicts the progressive steps in the pathogenesis of fever and hyperthermia. This review contains 1 highly rendered figure, 26 tables, and 107 references Key Words: collagen, vascular disease, febrile seizures, fever, heatstroke, hyperthermia, pyrogen

The neuroleptic malignant syndrome—a systematic case series analysis focusing on therapy regimes and outcome

Neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening antipsychotic-associated disorder that requires an efficient and timely therapy. The aim of the study was to compare the effectiveness of different NMS therapies and to analyze its outcome depending on NMS severity. Systematic search for NMS cases in biomedical databases. The focus of the analysis was on therapy with dantrolene, bromocriptine, and electroconvulsive therapy (ECT) when each was compared with symptomatic therapy. Primary outcomes were the survival rate and the duration of treatment. 405 case reports were included. Overall, no statistically significant differences regarding mortality rate or duration of treatment were found between dantrolene, bromocriptine, or ECT compared to supportive care. A subgroup analysis regarding NMS severity showed that the mortality under specific NMS pharmacotherapy (dantrolene, bromocriptine) and under ECT was significantly lower than under purely symptomatic therapy in severe NMS (P=0.018). The difference was not significant in mild and moderate cases. An overall superiority of the specific NMS therapy (dantrolene, bromocriptine, and ECT) was not found in this study. When regarding severity classification, specific therapies were superior but only in severe cases, and ECT showed the lowest mortality rate. In previous case series, an effect on survival or the duration of the disease could only be observed in part for specific therapies, but the evidence available is inconsistent. The results of this study support our hypothesis that NMS treatment with dantrolene, bromocriptine, and ECT is advantageous over purely symptomatic therapy in severe NMS cases.

Treatment of the Neuroleptic Malignant Syndrome in International Therapy Guidelines: A Comparative Analysis

The neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition associated to the use of antipsychotics. Since it requires rapid and efficient medical care, high-quality treatment guidelines should be available. In this article, we analyzed and compared different international therapy guidelines for the treatment of schizophrenia, in which NMS treatment recommendations might be contained. We performed an Internet-based search for schizophrenia guidelines via the website of the respective medical society. Guidelines in English, French, Italian, and German from countries whose medical care meets high standards were selected for further analysis and comparison of the NMS treatment recommendations (if present), and their underlying evidence. The NMS is mentioned in 12 of 14 guidelines. Only 9 report concrete therapy recommendations (benzodiazepines/dantrolene/bromocriptine/amantadine/intensive care and/or electroconvulsive therapy (ECT)), however, with high heterogeneity. Only 5 guidelines included all possible drug therapy options and ECT, but with differing combination strategies, dosages, application forms, and combinability of options. The level of evidence of the different recommendations was estimated as low. One-third of the selected guidelines do not report any NMS therapy recommendations. Most guidelines mentioning the NMS do not provide therapy recommendations that include all relevant treatment options. The results show a very high heterogeneity, and the recommendations and statements are of low-evidence levels. The lack of knowledge about the NMS and its treatment may delay the onset of therapy, impair the quality of treatment, and lead to a worse outcome or death.

A ROCK AND A HARD PLACE: A CASE OF CLOZAPINE-INDUCED NEUROLEPTIC MALIGNANT SYNDROME

SESSION TITLE: Critical Care 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Neuroleptic malignant syndrome (NMS) is a rare life-threatening neurologic emergency characterized by mental status changes, rigidity, fever, and dysautonomia. The incidence rate of NMS is 0.02-3% among patients taking typical or atypical neuroleptic agents; however, clozapine-induced NMS is a rarely-reported and unique entity as it doesn’t present with the four cardinal clinical features of NMS. We present a rare case of clozapine-induced NMS with the four cardinal features of NMS. CASE PRESENTATION: A 45-year-old man with history of schizoaffective disorder and catatonia was transferred from a local psychiatric hospital to the emergency department (ED) for evaluation of fever and altered mental status. Two days prior to the transfer, he was started on clozapine. In the ED, he had a temperature of 39.1° Celsius, blood pressure of 100/57 mmHg, respiratory rate of 24 breaths-per-minute, and heart rate of 118 beats-per-minute. The patient was diaphoretic, drooling, and shivering. He was lethargic with Glasgow Coma Scale of 8 and was therefore intubated. At that point, the rest of the examination was non-significant. Initial laboratory work-up including creatinine phosphokinase (CPK) was non-significant. Computed tomography (CT) scan of the head was normal. Lumbar puncture was performed and cerebrospinal fluid analysis was unremarkable. The patient was admitted to the intensive care unit (ICU) where he continued to develop fevers despite the use of antipyretics, cooling blankets, an d aggressive intravenous hydration. The fever spikes were associated with intermittent episodes of sinus tachycardia and fluctuations of his blood pressure. On day two, he developed rigidity, and blood work-up was significant for CPK level of 4419 U/L. He was started on benzodiazepines and dantrolene for a presumed diagnosis of NMS. However, his rigidity and fever didn’t improve. On day four, he developed ventilator-associated pneumonia. After a week in the ICU with no success in liberation of mechanical ventilation, family decided to shift care to comfort measures only. The patient perished a few hours later. DISCUSSION: Clozapine is considered among the most potent neuroleptic agents, with use reserved for treatment-resistant cases. Although it has many side effects, there are very few case reports about clozapine-induced-NMS. Risk factors for developing clozapine-induced NMS include young age, male gender, and history of catatonia. CONCLUSIONS: It is important to be aware of these risk factors for early recognition and treatment of NMS, given its high mortality rate of 10-30%. Reference #1: Clozapine-induced neuroleptic malignant syndrome: review and report of new cases.P. Sachdev, J. Kruk, M. Kneebone, D. KissaneJ Clin Psychopharmacol. 1995 Oct; 15(5): 365–371. DISCLOSURES: No relevant relationships by Abdullah Chahin, source=Web Response No relevant relationships by Faeq Kukhon, source=Web Response No relevant relationships by Mahmoud Mowafy, source=Web Response No relevant relationships by Magaly Sazani, source=Web Response No relevant relationships by Abraham Walusimbi, source=Web Response

Neuroleptic Malignant Syndrome

To provide an overview of neuroleptic malignant syndrome (NMS) for the general practitioner with the most up-to-date information on etiology, workup, and management. The search using PubMed included articles with the key words neuroleptic malignant syndrome, antipsychotics, neuroleptics, diagnosis, and treatment of neuroleptic malignant syndrome published in English from January 2000 to 2017. Single-case reports and articles dealing with the pediatric patient population were excluded. Over 4,000 articles met the search criteria. After eliminating single-case reports, pediatric cases, reports in pregnant patients, and duplicates, 87 articles underwent screening. Forty-two articles were included in this review. The literature is rich with cases of NMS associated with the use of neuroleptics and various medications with neuroleptic-like effects. Questions remain with regard to pathophysiology and optimal treatment. NMS is a rare but potentially lethal consequence of the use of antipsychotic medications that requires familiarity with the condition in order to rapidly recognize its onset and appropriately intervene. NMS mortality rates have declined over the past 30 years, most likely due to early recognition of the syndrome and appropriate intervention. Nonetheless, clinicians, especially primary care clinicians who are using this class of drugs more often for adjunctive treatments, must be cognizant of this syndrome and the implications of their use.​.

Neuroleptic Malignant Syndrome.

To review evidence for the treatment of neuroleptic malignant syndrome (NMS) and to discuss how to rechallenge patients with neuroleptics when continued pharmacotherapy for chronic psychological illness is required. A PubMed search was conducted through March 2016 using available medical subject heading (MeSH) terms and keywords that included neuroleptic malignant syndrome, treatment, dantrolene, and bromocriptine. A manual search of article reference sections followed. Case reports and case series in English that discussed NMS and atypical NMS treatment as well as neuroleptic rechallenge were included for review. The reported incidence of NMS was 0.02% to 0.03%, with a mortality rate of 5.6%. Current literature on NMS is primarily retrospective and emphasizes diagnostic criteria, causative agents, and potential pharmacotherapy. Details regarding timing of administration, dose, and duration of pharmacotherapy are inconsistently reported. Reported dosing strategies and outcomes have been summarized. Instances of rechallenge were infrequently reported but demonstrate that recurrence may happen at any time after NMS resolution. Recommendations regarding safe rechallenge are provided. NMS is a rare adverse drug reaction, with a complex pathophysiology and presentation. Timely diagnosis and discontinuation of antipsychotic therapy is the first-line treatment, followed by supportive care and pharmacotherapy. Antipsychotic rechallenge is often required and should be attempted only after a drug-free period and with a different agent, slowly titrated with close monitoring.

Neuroleptic syndrome among patients receiving antipsychotic drugs-review

Neuroleptic Malignant Syndrome is occasional but deadly reaction, which results from treatment with antipsychotic medications. Risk aspects include the following: dehydration, agitation, and history of neuroleptic malignant syndrome. Despite the fact that Neuroleptic Malignant Syndrome has been described as adverse effect from treatment with antipsychotic medications, patients suffering with chemical imbalance of brain or mood disorders, especially when treated with lithium, fall in to higher risk group. Standard criteria for the diagnosis of Neuroleptic Malignant Syndrome highlight the following signs and symptoms: muscle rigidity, hyperthermia, alteration in mental status, and autonomic dysfunction. Syndrome usually lasts from 7 to 10 days in simple and uncomplicated patients who receiving neuroleptics orally. Early detection and diagnosis of syndrome are up the most importance, where discontinuance of triggering medication, managing of fluid balance, control of body temperature and close observation for complications takes place. Use of dopamine agonists should be advised in more complex cases. Electroconvulsive therapy has also been effective in a few cases. In this article author reviews the proposed pathology, symptoms, complications, and treatment of Neuroleptic malignant syndrome

Acute Kidney Injury with Epstein Barr Virus-Associated Hemophagocytic Syndrome

A 59-year-old man, who was treated for schizophrenia and psoriasis vulgaris with risperidone and cyclosporine, presented with high fever and myalgia. Those did not respond to treatment for neuroleptic malignant syndrome for two weeks, and multiple organ dysfunction developed, so he was admitted to our hospital, but died two days later. Autopsy detected the hemophagocytosis, Epstein Barr Virus (EBV)-reactivated cells, and the absence of glomerulonephritis and interstitial tubulitis. We considered that hemophagocytic syndrome (HPS) and myalgia were caused by reactivated EBV and the viremia under immunosuppression, and renal failure was caused by sepsis-like state by cytokine storm of HPS.

Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Perspective.

Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening sideeffect that can occur in response to treatment with antipsychotic drugs. Symptoms commonly include hyperpyrexia, muscle rigidity, autonomic dysfunction and altered mental status. In the current review we provide an overview on past and current developments in understanding the causes and treatment of NMS. Studies on the epidemiological incidence of NMS are evaluated, and we provide new data from the Canada Vigilance Adverse Reaction Online database to elaborate on drug-specific and antipsychotic drug polypharmacy instances of NMS reported between 1965 and 2012. Established risk factors are summarized with an emphasis on pharmacological and environmental causes. Leading theories about the etiopathology of NMS are discussed, including the potential contribution of the impact of dopamine receptor blockade and musculoskeletal fiber toxicity. A clinical perspective is provided whereby the clinical presentation and phenomenology of NMS is detailed, while the diagnosis of NMS and its differential is expounded. Current therapeutic strategies are outlined and the role for both pharmacological and non-pharmacological treatment strategies in alleviating the symptoms of NMS are discussed.

Early Diagnosis and Treatment of Neuroleptic Malignant Syndrome In Patients with Head Trauma

Genellikle nöroleptik ilaç kullanımı ile ortaya çıkan ve tatmin edici tedavisi bulunmayan Nöroleptik Malign Sendrom (NMS), ender görülen ve yaşamı tehdit edici nörolojik acillerdendir. Klinik olarak hipertermi, kas rijiditesi, otonomik disfonksiyon ve şuur bozuklukları; laboratuvar bulgusu olarak ise serum kreatinfosfokinaz (CPK) düzeyinde yükselme ve lökositoz görülebilir. Risk faktörleri arasında adolesan yaş, erkek cinsiyet, elektrolit düzensizlikleri, dehidratasyon, düşük serum demir düzeyi, antiemetiklerin kullanımı, mental retardasyon, travma, organik beyin sendromu, ekstrapiramidal bozukluklar (Parkinson hastalığı gibi), alkolizm ve malnutrisyon sayılabilir. Bu makalede yoğun bakımda travmatik beyin hasarı (TBH) nedeniyle takip ettiğimiz üç NMS olgusu sunulmuştur. Ayrıca NMS tanı ve tedavisi de tartışılmıştır.

EPA-1364 – Malignant catatonia and neuroleptic malignant syndrome: two sides of the same coin?

Catatonia is a neuropsychiatric syndrome that appears in medical, neurological and psychiatric disorders. The diversity of its presentation led to the identification of different subtypes, one of them called the’malignant catatonia’ (MC). This subtype shares many characteristics with the neuroleptic malignant syndrome (NMS), which could reflect a similar pathophysiology. It will be made a revision of malignant catatonia/NMS based on a case report. Presentation of the case report and review of the literature in PubMed and reference books. A Bipolar patient with 54 years developed a clinical picture characterized by mutism, negativism and immobility. The clinical picture rapidly worsened with the onset of great muscle rigidity, autonomic changes (hemodynamic instability, diaphoresis), leukocytosis and rhabdomyolysis. Supportive care was started, aripiprazole was suspended and the patient started electroconvulsive therapy (ECT) in combination with benzodiazepines which resolved the clinical picture. Before discharge aripiprazole was reintroduced without recurrence of the symptoms. The malignant catatonia was described before the introduction of psychotropic agents and studies suggest that it is indistinguishable from NMS, either clinically or by laboratory tests. Whether or not NMS and MC are the same syndrome with different triggers, they are life threatening. In this case ECT showed high efficacy leading us to assume catatonia as the probable syndrome. However, some studies report the efficacy of this procedure in the treatment of NMS as well.

Catatonia and Neuroleptic Malignant Syndrome

We present the history of four bipolar patients who developed neuroleptic malignant syndrome (NMS) after antipsychotic treatment, focusing on the relationship between NMS and catatonia. In all cases, the administration of antipsychotics has been suspended as soon as fever and autonomic disturbances occurred. A supportive therapy was initiated to stabilize general conditions, then every patient started electroconvulsive therapy (ECT) in combination with benzodiazepines (BDZ). The risk of complications was reduced by the quick adoption of supportive care, whereas the combination of ECT and BDZ was effective in resolving the clinical picture. These cases may provide further support to the hypothesis that catatonia and NMS are disorders pertaining to the same spectrum of illness because the onset or exacerbation of catatonic symptoms coincided with the administration of antipsychotics. Our experience confirms the efficacy and safety of ECT in combination with BDZ as treatment of NMS and residual catatonia.

Catatonia and neuroleptic malignant syndrome: two disorders on a same spectrum? Three case reports

The authors present the cases of three bipolar patients who developed Neuroleptic Malignant Syndrome (NMS) after antipsychotic treatment, both typical and atypical, focusing on relationship between NMS and catatonia. In all three cases, administration of antipsychotics has been stopped at once, when fever and autonomic disturbances occurred. A supportive therapy (including rehydration, electrolyte restoration and blood pressure aids, together with antipyretics, antibiotics and anticoagulants) was prescribed in order to stabilize general conditions. Every patient started then Electroconvulsive Therapy (ECT) in combination with benzodiazepines. High risk of complications and lethal outcome, associated with NMS, were successfully reduced by the tempestive adoption of a supportive care, while combination between ECT and BDZ was effective in resolution of clinical picture. DISCUSSIONS; These cases may provide further evidences about hypothesis of catatonia and NMS as disorders on the same spectrum. In one patient, NMS occurred overlapping with a previous catatonic state, while two others exhibited catatonic features after resolution of NMS. However, catatonic symptoms arose or worsened with administration of antipsychotics, supporting hypothesis of neuroleptic-induced catatonia as a step of progressive development of NMS. Our experience also confirms efficacy and safety of ECT in combination with BDZ as treatment of NMS and residual catatonia.

Propofol-Remifentanil Combination for Management of Electroconvulsive Therapy in a Patient with Neuroleptic Malignant Syndrome

Electroconvulsive therapy can be effective in severe or treatment resistant neuroleptic malignant syndrome patients. Anesthesia and use of muscle relaxant agents for electroconvulsive therapy in such patients may encounter anesthesiologists with specific challenges. This case report describes successful management of anesthesia in 28-year-old male patient undergoing eight electroconvulsive therapy sessions for treatment of neuroleptic malignant syndrome.

Neuroleptic malignant syndrome: a case treated with bromocriptine

Neuroleptic malignant syndrome: a case treated with bromocriptine Neuroleptic malignant syndrome (NMS) is a potentially fatal syndrome which is rarely seen during treatment with antipsychotic medications. In this paper, the treatment of NMS that developed after a dose increase in oral antipsychotic drug therapy with depot antipsychotics in a patient with schizoaffective disorder, who has used antipsychotic medications for a long time and was hospitalized many times was reported and the treatment approach and bromocriptine use in NMS was discussed.