Heat stroke during long-term clozapine treatment: should we be concerned about hot weather? / Heat stroke durante tratamento de longo prazo com clozapina: devemos nos preocupar com o tempo quente?

Objective To describe the case of a patient with schizophrenia on clozapine treatment who had an episode of heat stroke. Case description During a heat wave in January and February 2014, a patient with schizophrenia who was on treatment with clozapine was initially referred for differential diagnose between systemic infection and neuroleptic malignant syndrome, but was finally diagnosed with heat stroke and treated with control of body temperature and hydration. Comments This report aims to alert clinicians take this condition into consideration among other differential diagnoses, especially nowadays with the rise in global temperatures, and to highlight the need for accurate diagnosis of clinical events during pharmacological intervention, in order to improve treatment decisions and outcomes.

Objetivo Descrever o caso de um paciente com esquizofrenia em tratamento com clozapina acometido por um episódio de heat stroke. Descrição do caso Durante uma onda de calor em janeiro e fevereiro de 2014, um paciente com esquizofrenia em tratamento com clozapina foi inicialmente encaminhado para diagnóstico diferencial de infecção sistêmica e síndrome neuroléptica maligna, tendo obtido o diagnóstico final de heat stroke, tratado com controle de temperatura corporal e hidratação. Comentários Este relato de caso tem como objetivo alertar os clínicos para este diagnóstico diferencial, que pode surgir com mais frequência à medida que as temperaturas globais continuarem a aumentar, e também destacar a importância da realização de um diagnóstico mais acurado, que possa melhorar as decisões de tratamento e os desfechos clínicos para os pacientes.

Síndrome neuroléptico maligno: caso clínico / Neuroleptic Malignant Syndrome: Clinical case

El Síndrome Neuroléptico Maligno (SNM) descrito por primera vez hace casi cinco décadas, es una peculiar y peligrosa complicación del tratamiento con fármacos antipsicóticos, que se caracteriza por fiebre, rigidez muscular severa y cambios en el estado autonómico y mental. Es una complicación imprevisible y rara, potencialmente mortal de medicamentos antipsicóticos, presuntamente relacionada con el bloqueo dopaminérgico. Prácticamente todos los neurolépticos son capaces de inducir el síndrome, incluyendo laclozapina, risperidona y olanzapina. Estimaciones retrospectivas de incidencia varían desde 0.02 hasta 3.23% de los pacientes psiquiátricos que reciben neurolépticos, tasas de mortalidad reportados están en el rango de 10-20%; es más común en pacientes con esquizofrenia o trastornos afectivos.Se presenta el caso clínico de una paciente que desarrollo Síndrome Neuroléptico Maligno: femenina de18 años de edad, con diagnóstico de esquizofrenia hebefrenica, tratada con antipsicóticos por 39 días, inicia con sialorrea, rigidez generalizada y sudoración profusa. Al examen físico se encontró: ritmo cardiaco de 140 latidos por minuto, presión arterial de 130/90 mmHg, frecuencia respiratoria de 26 por minuto, temperatura de 38.6°C. Los estudios de laboratorio relevantes fueron: recuento de leucocitos de 11,170 células ml y nivel de creatina quinasa de 2,563 UI. Se realizó el diagnóstico de SNM y se inició tratamiento con bromocriptina 5mg vía oral cada 6 horas durante 10 días; la paciente respondió de forma favorable. A continuación se revisa la incidencia, las características clínicas, los factores de riesgo, la mortalidad y el tratamiento del SNM...

Síndrome neuroléptica maligna / Neuroleptic malignant syndrome

JUSTIFICATIVA E OBJETIVOS: A síndrome neuroléptica maligna (SNM) apresenta incidência muito variável na população, sem haver uma associação significativa com fatores de risco sociais, étnicos ou sazonais. Em 90% dos casos o quadro clínico se completa nas primeiras quatro a oito horas, após os primeiros sintomas, podendo ter evolução grave e fatal se a conduta não for feita de forma correta, tornando seu conhecimento de extrema valia. O objetivo deste estudo foi rever os fatores de risco, quadro clínico, fisiopatogenia, diagnóstico diferencial e tratamento da SNM para melhor qualidade de vida dos pacientes. CONTEÚDO: Utilizou-se o portal Capes como base da pesquisa em periódicos que abordassem o tema, utilizando-se artigos de revisão, excluindo-se relatos de caso, as palavras-chaves usadas durante a busca foram: Síndrome Neuroléptica Maligna. Seu conhecimento se torna importante ao ter um diagnóstico de exclusão, que feito em um curto espaço de tempo possui significância na evolução do quadro. CONCLUSÃO: A falta de conhecimento sobre a SNM significa um risco potencial importante ao paciente, inclusive podendo levá-lo ao óbito, além de haver uma evolução rápida. Por ser uma complicação idiossincrática, sua importância é ainda maior. Entretanto com o cuidado correto a reversão do quadro é possível.

BACKGROUND AND OBJECTIVES: Neuroleptic malignant syndrome (NMS) has a highly variable incidence in the population without a significant association with social, ethnic or seasonal risk factors. In 90% of cases, the clinical picture is complete in the first 4 to 8 hours after the first symptoms; evolution may be serious and fatal if the treatment is not correct; thus, its knowledge is invaluable. The objective of this study was to review risk factors, clinical features, pathophysiology, differential diagnosis and treatment of the NMS to improve patients' quality of life. CONTENTS: CAPES website was used as a basis for the research in journals that addressed this issue, using review articles and excluding case reports; the key words used during the search were: Neuroleptic Malignant Syndrome. The knowledge of this syndrome becomes important when we make an exclusion diagnosis, which has significance in the evolution of the clinical picture when made in a short time. CONCLUSION: The lack of knowledge about NMS implies potential risk for the patient, may lead to fast progression and even to death. Because it is an idiosyncratic complication, its importance is even greater. However, with the right care, there is a possibility of clinical picture reversal.

Neuroleptic malignant syndrome / Síndrome neuroléptica maligna

Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse event associated with the use of antipsychotics (AP). The objective of this study was to investigate the profile of cases of NMS and to compare our findings with those published in similar settings. A series of 18 consecutive patients with an established diagnosis of NMS was analyzed, gathering data on demography, symptoms and signs. Two thirds of all cases involved woman with a past medical history of psychiatric disorder receiving relatively high doses of AP. The signs and symptoms of NMS episodes were similar to those reported in other series and only one case had a fatal outcome, the remaining presenting complete recovery. As expected, more than two thirds of our cases were using classic AP (68 percent), however the clinical profile of these in comparison with those taking newer agent was similar. Newer AP also carry the potential for NMS.

A síndrome neuroléptica maligna (SNM) é um evento adverso potencialmente fatal associado ao uso de antipsicóticos (AP). O objetivo deste estudo foi investigar as características clínicas de cases da SNM e comparar nossos resultados com os publicados na literatura. Uma série de 18 pacientes com diagnóstico confirmado de SNM foram analisados, associando dados demográficos, apresentação clínica, diagnóstico e tratamento. Dois terços dos casos envolveram mulheres com antecedentes psiquiátricos que recebeceram doses relativamente altas de AP. Os sinais e sintomas foram semelhantes àqueles já relatados na literatura e a maioria dos pacientes teve uma recuperação completa, exceto por um caso com desfecho fatal. Houve predomínio de pacientes que usam medicamentos neurolépticos clássicos (68 por cento), porém não houve diferença nas manifestações destes casos em relação àqueles que usavam AP novos. AP mais novos também têm o potencial de causar SNM.

Electroconvulsive therapy in drug resistant neuroleptic malignant syndrome.

We report a case of a 20 years female referred to us with a history of a brief psychotic episode for which she was given inj. Haloperidol. The patient presented in an unconscious state with high grade fever. The diagnosis was kept as neuroleptic malignant syndrome after ruling out other possibilities. The patient did not respond to Bromocriptine and Dantrolene. With the recent evidence of electroconvulsive therapy being useful in these patients, we went ahead with the same. We present this case to share our experience of the excellent response of neuroleptic malignant syndrome to electroconvulsive therapy.

Síndrome neuroléptica maligna de paciente em uso de olanzapina / Neuroleptic malignant syndrome in patient using olanzapine

A síndrome neuroléptica maligna (SNM) é uma reação idiossincrásica rara, extremamente grave e potencialmente fatal ao uso de antipsicóticos, tanto típicos quanto atípicos, bem como drogas de ação dopaminérgica. O diagnóstico fundamenta-se em critérios clínicos e laboratoriais e exclusão de outras condições médicas gerais ou psiquiátricas que melhor expliquem os sintomas. Segundo o DSM-IV, os principais critérios são rigidez muscular grave e temperatura elevada, associadas ao uso de medicação antipsicótica. Foi relatado um caso de paciente com 30 anos manifestando história de transtorno afetivo bipolar, que apresentou sinais e sintomas consistentes com SNM, após três semanas de tratamento com olanzapina. Esse relato visa a discutir o risco da SNM ao uso de antipsicóticos atípicos, bem como a importância de diagnóstico precoce e intervenção imediata.

Neuroleptic malignant syndrome (NMS) is an idiosyncratic, serious and potentially fatal disorder observed in patients who receive treatment with neuroleptics, typical and atypical, as well as medications with dopaminergic effects. The diagnosis is based on clinical and laboratory criteria and the exclusion of other general medical or psychiatric conditions that could best explain the symptoms. The main criteria according to DSM-IV are severe rigidity and fever associated with the use of antipsychotic medication. We present a case of a 30-year-old female with history of bipolar affective disorder that developed signs and symptoms consistent with NMS after three weeks of treatment with Olanzapine. This case aims to address the risk of NMS associated atypical antipsychotic, as well as the importance of an early diagnosis and immediate intervention.

Atypicality in presentation of neuroleptic malignant syndrome caused by olanzapine.

Neuroleptic malignant syndrome (NMS) is the most serious of acute neurological side effects produced by antipsychotic medication, characterized by hyperthermia, rigidity, altered consciousness and autonomic dysfunction, the prevalence of which varies from 0.4-1.4%. NMS is usually seen in treatment with high potency typical antipsychotics and very rarely with atypical antipsychotics. However, NMS cases have been reported with risperidone, clozapine, olanzapine and quetiapine. The presentations of NMS have often varied and we report another atypicality in presentation of NMS due to olanzapine use.

Neuroleptic malignant syndrome: a sixteen years retrospective review

To study demographic characteristics, psychiatric diagnosis, type of neuroleptic drugs administered, course of illness, management and outcome. Retrospective chart review study. This study was carried out for sixteen years [1988-2004] in the Psychiatry unit, Aga Khan University Hospital, Karachi. Sample consisted of 25 cases of Neuroleptic Malignant Syndrome in which 13 were males and 12 were females. The record was taken from the health information management system which keeps a comprehensive chart of each patient. This renders the files retrievable through computer generated search. A specific data collection form was designed for extraction of relevant data. The data was analyzed using SPSS version 13.0. Twenty five cases were identified, of which thirteen were males. Mean age was 45 years [range 20-74 years]. Bipolar affective disorder was the most common diagnosis followed by schizo-affective disorder, schizophrenia, postpartum psychosis, dementia and Parkinsonism. 48% of the patients had previous history of neuroleptic use, while 28% received neuroleptics for the first time. Among neuroleptic users, 20% were on long-acting depot antipsychotics. 52% received per-oral dose [PO], while 32% received intramuscular [IM] dose. 56% patients were on other concomitant medications among which Lithium was the most common [16%]. 96% patients had the cardinal symptoms of fever, rigidity and increased creatine phosphokinase [CPK]. 96% had associated delirium, 80% showed autonomic instability with fluctuation in pulse and blood pressure. Electrolyte disturbance was seen in 84% and diaphoresis with leukocytosis was present in 68% patients. NMS was associated with high ambient temperature with mean temperature of 39.20 C [S.E. 0.3]. Discontinuation of neurolpetic medications and supportive care was carried out in all cases. In our case series we observed mortality rate of 16%. Out of 25 patients, 21 recovered with early diagnosis and adequate management. Risk of NMS can be minimized by use of low potency or atypical antipsychotics, cautious use of concomitant medications and depot preparations and initiation of neurolpetics at lower dose with careful monitoring. With good supportive medical care mortality can be substantially minimized

Neuroleptic malignant syndrome: a review and report of six cases.

The typical symptoms and signs of neuroleptic malignant syndrome (NMS) consist of fever muscle rigidity (stiffness, myoclonus, rod-like), alterations of consciousness (confusion, agitation, aggression, or catatonia), autonomic nervous system disturbances (i.e., hypertension, tachycardia, tachypnea, profuse sweating, and urine incontinence), abnormal blood tests such as low serum electrolytes, elevated serum creatinine phosphokinase (CPK) level, and leukocytosis. Muscle rigidity is often associated with myonecrosis, myoglobinuria, and elevated serum CPK. The mortality among NMS cases is in the 10 to 70% range depending on the severity of the symptoms and time of therapeutic approach. Mandatory therapy should include removal of causative agents, correction of body fluid and electrolytes, administration of benzodiazepine, clonazepam and bromocriptine (dopamine agonist), proved life-saving medications. The authors reported herein six cases with unusual clinical features of NMS. Four of them had been on antipsychotic for a year before becoming anorexic, dehydrated, agitated, and violent with paranoid delusion. One instance with underlying delirium tremens developed NMS after receiving haloperidol (30 mg IV) in addition to diazepam (200 mg IV) within 24 hours. Another patient was found to suffer from severe NMS after receiving bupropion (Dopamine inhibitor antidepressant) 300 mg/day. All patients displayed cardinal signs and symptoms of NMS in addition to dehydration and pallor. They were treated in the psychiatric ward and recovered rapidly from NMS after receiving clonazepam and bromocriptine and removal of the offending agents.

Síndrome neuroléptico maligno: informe de un caso / Neuroleptic malignant syndrome: a report of a case

Reportamos el caso de un hombre de 48 años de edad, con historia de parálisis cerebral infantil y epilepsia neonatal, al que se le dieron neurolépticos 48 horas antes del inicio de su padecimiento, el síndrome neuroléptico maligno, el cual se caracterizó por hipertermia, aumento del tono muscular, deshidratación, incremento progresivo de la creatinina fosfoquinasa (CPR) y azoados. El tratamiento elegido fue la fluidoterapia y la administración de fármacos dopaminérgicos, a los que reaccionó favorablemente. Esta afección ocurre como complicación del tratamiento con neurolépticos y su incidencia es del 0.2 al 0.5 por ciento, con una mortalidad aproximada del 20 por ciento, la cual depende directamente de la complicación desarrollada; la más grave es la insuficiencia renal aguda producida por mioglobinuria secundaria a rabdomiolisis.

Síndrome Neuroléptico Maligno / Malignant neuroleptic syndrome

El síndrome neuroléptico maligno constituye una complicación infrecuente asociada con el uso de neruolépticos. El cuadro establecido tiene toma de conciencia, rigidez generalizada, disautonomías asociadas con rabdomiólisis con creatinin fosfoquinasa elevada. Se presenta un paciente del sexo masculino de 31 años de edad, con antecedentes de cuadros delirantes alucinatorios a los 7 años, a los 21 y el actual. Los primeros síntomas comenzaron 2 meses antes de su ingreso, con alucinaciones auditivas. Comienza tratamiento con haloperidol; al no mejorar el cuadro psicótico y estar muy agresivo deciden asociarle clorpromazina. Un mes después presenta fiebre y manifestaciones respiratorias. Días después empeora la fiebre, aparece la rigidez axial y la sialorrea. Es trasladado a cuidados intensivos con el diagnóstico de síndrome neuroléptico maligno, comienza tratamiento específico, no obstante fallece a los 3 días. Se concluye que el síndrome neuroléptico maligno es una complicación neurológica infrecuente pero muy grave, con una elevada mortalidad en los casos no tratados de manera precoz