SESSION TITLE: Critical Care Cases - Student/Resident
SESSION TYPE: Student/Resident Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM
INTRODUCTION: Neuroleptic malignant syndrome (NMS) is a life-threatening, idiosyncratic reaction to antipsychotic medications affecting the central dopaminergic neurotransmission. We report a case of refractory NMS, who failed medical treatment, but displayed marked improvement after receiving ECT.
CASE PRESENTATION: A 64 year-old female with history of bipolar presented to our facility with 2 day history of altered mental status and fever. She was maintained on Olanzapine and Divalproex sodium. She presented with fever of 38.60 C, HR=130 b/m and BP=160/90 mm of Hg. On physical examination, she was unresponsive; she had extreme lead pipe rigidity of all 4 extremities with resting tremor. Labs revealed rhabdomyolysis, leucocytosis and acute kidney injury. The workup for infection including CNS infection was negative. The differential diagnosis of neuroleptic malignant syndrome vs lethal catatonia was considered. Despite cessation of antipsychotic medications, supportive care and pharmacotherapy with max dose of Bromocriptine and Dantrolene for 3 weeks, she had no improvement in her neurological status. She remained comatose, rigid and ventilator dependent. Thereafter, a decision was made to begin ECT for the treatment of refractory neuroleptic malignant syndrome. She had excellent neurological recovery after 4 treatments of ECT.
DISCUSSION: NMS is characterized by marked and sudden reduction in central dopaminergic activity resulting from D2 dopamine receptor blockade within the nigrostriatal, hypothalamic, and mesolimbic/cortical pathways, resulting in triad of rigidity, hyperthermia, and encephalopathy. This state may be induced at any time during treatment by essentially all antipsychotics or by stopping or reducing dose of dopamine agonists like levodopa. Without swift recognition of these symptoms as being part of a lethal syndrome, permanent neurologic damage, multi-organ failure or death may occur. Treatment includes immediately stopping the offending agent, supportive measures and pharmacological interventions with muscle relaxant (Dantrolene) and dopamine agonist (Bromocriptine). ECT can be used as a last resort of treatment for refractory cases of NMS.
CONCLUSIONS: NMS is a neurological emergency, and early diagnosis and treatment of NMS is required to reduce morbidity and mortality. ECT is the preferred treatment in refractory NMS, and in cases where lethal catatonia cannot be ruled out.
Reference #1: 1. Bhanushali MJ, Tuite PJ. The evaluation and management of patients with neuroleptic malignant syndrome. Neurologic Clin. 2004;22(2):389-411
Reference #2: 2. Trollor JN, Sachdev PS. Electroconvulsive treatment of neuroleptic malignant syndrome: a review and report of cases. Aust N Z J Psychiatry. 1999 Oct;33(5):650-9
Reference #3: 3. Perry P, Wilborn C. Serotonin syndrome vs neuroleptic malignant syndrome: A contrast of causes, diagnoses, and management. Annals of Clinical Psychiatry. Vol. 24 No. 2 May 2012
DISCLOSURE: The following authors have nothing to disclose: Rizwan Malik, Rachael Klein, Amit Chopra
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