Neuroleptic malignant syndrome

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Neuroleptic malignant syndrome
ICD-10 G21.0
ICD-9 333.92
DiseasesDB 8968
eMedicine emerg/339  med/2614 ped/1581

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Neuroleptic malignant syndrome (NMS) is a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.

Causes

NMS is caused almost exclusively by antipsychotics, including all types of neuroleptic medicines along with newer antipsychotic drugs.[1] The higher the dosage, the more common the occurrence. Rapid and large increases in dosage can also trigger the development of NMS. Other drugs, environmental or psychological factors, hereditary conditions, and specific demographics may cause greater risk, but to date no conclusive evidence has been found to support this. The disorder typically develops within two weeks of the initial treatment with the drug, but may develop at any time the drug is being taken. NMS may also occur in people taking a class of drugs known as dopaminergics when the dosage is reduced (i.e Levodopa).

Pathophysiology

The mechanism is thought to depend on decreased levels of dopamine due to:

Signs and Symptoms

The first symptom to develop is usually muscular rigidity, followed by high fever and changes in cognitive functions. Other symptoms can vary, but may be unstable blood pressure, confusion, coma, delirium, muscle tremors, etc. Once symptoms do appear, they rapidly progress and can reach peak intensity in as little as three days. These symptoms can last anywhere from eight hours to forty days.

A raised creatine phosphokinase (CPK) plasma concentration will be reported due to increased muscular activity. The patient may be hypertensive and suffering from a metabolic acidosis. A non-generalised slowing on an EEG is reported in around 50% of cases.

Unfortunately, symptoms of NMS are sometimes misinterpreted by doctors as symptoms of mental illness, delaying treatment.[3]

Mnemonic

A mnemonic used to remember the features of NMS is: FEVER.[4]

Prognosis

As with most illnesses, the prognosis is best when identified early and treated aggressively. In these cases NMS is usually not fatal, although there is currently no agreement on the exact mortality rate for the disorder. Studies have given the disorder a mortality rate as low as 5% and as high as 76%, although most studies agree that the correct percentage is in the lower spectrum, perhaps between 10% - 15%. Re-introduction to the drug that originally caused NMS to develop may also trigger a recurrence, although in most cases it does not.

Treatment

Although treatment is not always necessary, it will help to cure the disease and prevent fatal developments from occurring. The first step in treatment is generally to remove the patient from any neuroleptic or antipsychotic drugs being taken and to treat fever aggressively. Many cases require intensive care, or some kind of supportive care at the minimum. Depending on the severity of the case, patients may require other treatments to contend with specific effects of the disorder. These include circulatory and ventilatory support, the drugs dantrolene sodium, bromocriptine, apomorphine and electroconvulsive therapy (ECT) if medication fails.

Differential diagnosis

NMS and serotonergic syndrome

The clinical features of NMS and serotonergic syndrome are very similar. This can make differentiating them very difficult.[5]

Features, classically present in NMS, that are useful for differentiating the two syndromes are:[6]

  • Fever
  • Muscle rigidity
  • Laboratory Values (WBC & CK)

History

NLM was known about as early as 1956, shortly after the introduction of the first phenothiazines, and is derived from the French syndrome malin des neuroleptiques.[7]

References

  1. Theodore I. Benzer, MD, PhD (2005). "Neuroleptic Malignant Syndrome". Emedicine.
  2. Mihara K, Kondo T, Suzuki A; et al. (2003). "Relationship between functional dopamine D2 and D3 receptors gene polymorphisms and neuroleptic malignant syndrome". Am. J. Med. Genet. B Neuropsychiatr. Genet. 117 (1): 57–60. doi:10.1002/ajmg.b.10025. PMID 12555236.
  3. Stacy Milbouer, "Quest for the truth", Nashua Telegraph http://www.nashuatelegraph.com/apps/pbcs.dll/article?AID=/20050424/NEWS01/104240081
  4. Identify neuroleptic malignant syndrome. schizophrenia.com URL: http://www.schizophrenia.com/sznews/archives/002054.html. Accessed: July 2, 2006.
  5. Christensen V, Glenthøj B (2001). "[Malignant neuroleptic syndrome or serotonergic syndrome]". Ugeskr Laeger. 163 (3): 301–2. PMID 11219110.
  6. Birmes P, Coppin D, Schmitt L, Lauque D (2003). "Serotonin syndrome: a brief review". CMAJ. 168 (11): 1439–42. PMID 12771076. Full Free Text.
  7. Friedberg JM. Neuroleptic malignant syndrome. URL: http://www.idiom.com/~drjohn/biblio.html. Accessed: July 3, 2006.

External links

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