Síndrome neuroléptico maligno asociado con intoxicación aguda por un organofosforado: reporte de caso / Neuroleptic malignant syndrome associated with acute organophosphate poisoning: Case report

El síndrome neuroléptico maligno es una condición clínica rara y potencialmente letal que frecuentemente se asocia con el uso de antipsicóticos. En la literatura especializada se encontró únicamente un reporte de caso relacionado con la ingestión de organofosforados. Se presenta un paciente con un cuadro clínico correspondiente al síndrome neuroléptico maligno posterior a la ingestión de clorpirifós. Como resultado de un intento de suicidio con el mencionado organofosforado, el hombre de 57 años presentó deterioro agudo del estado de consciencia, evolución neurológica tórpida e inestabilidad autonómica asociada a rigidez e hipertermia persistentes, así como incremento de la creatina-fosfocinasa (creatine phosphokinase, CPK). Se le administró tratamiento con bromocriptina, con lo cual el cuadro clínico remitió, y fue dado de alta sin secuelas. El diagnóstico del síndrome neuroléptico maligno es clínico y debe contemplarse en cualquier caso de exposición a sustancias que puedan resultar en una desregulación de la neurotransmisión dopaminérgica, con el fin de iniciar el tratamiento oportuno y contrarrestar efectivamente los efectos.

Neuroleptic malignant syndrome is a rare and potentially fatal clinical condition frequently associated with the use of antipsychotics. In the literature, there is only one case report associated with the intake of organophosphates. We present the case of a patient who presented with a clinical picture compatible with neuroleptic malignant syndrome, after the ingestion of an organophosphate (chlorpyrifos). A 57-year-old man who consulted for attempted suicide, acute deterioration of consciousness, torpid neurological evolution, and associated autonomic instability associated with rigidity, persistent hyperthermia, and elevated CPK. Bromocriptine treatment was offered, which resolved the clinical picture. The association with the ingestion of an organophosphate was established, and he was discharged without sequelae. The diagnosis of neuroleptic malignant syndrome is clinical and should be considered in any case of exposure to substances that may lead to dysregulation of dopaminergic neurotransmission in order to initiate timely therapy and impact outcomes.

Rigidez muscular, trastorno de sensorio y antipsicóticos: Reporte de caso / Muscle rigidity, sensory disorder and antipsychotics: a case report

En los servicios de emergencias que atienden a una gran población, muchas veces se encuentran cuadros aislados, como deshidratación severa, hipernatremia o hiponatremia, injuria renal aguda, trastorno de sensorio, entre otras. Sin embargo, muchos de estos cuadros forman parte de una sola patología, y si no se hace una unidad clínica en el momento adecuado, la morbimortalidad se puede incrementar drásticamente. Sobre todo, en enfermedades con baja frecuencia, muy raras o poco habituales, como la que se narrará a continuación, podría empeorar el estado crítico del paciente si no se detecta a tiempo o no se maneja adecuadamente. Este caso clínico es el de una paciente mujer de 74 años, con antecedente de patología psicótica con tratamiento irregular que, tras ingerir carbamazepina y risperidona, presenta los síntomas típicos y poco frecuentes del síndrome neuroléptico maligno (SNM).

In emergency rooms with large numbers of assigned population, we often see isolated conditions, such as severe dehydration, hypernatremia or hyponatremia, acute kidney injury, sensory disorder, among others. However, many of these conditions are part of a single disease and, if they are not gathered together as a medical unit at the right time, morbidity and mortality may drastically increase, especially in the event of diseases with a very rare or unusual frequency. Such is the case of the following disorder, which could worsen the critical condition of the patient if it is not detected on time or not treated appropriately. This clinical case addresses a 74-year-old female patient who reports a history of psychotic disorder with irregular treatment and, after the intake of carbamazepine and risperidone, presents the typical and infrequent symptoms of neuroleptic malignant syndrome (NMS).

Rhabdomyolysis and Neuroleptic Malignant Syndrome Associated with Very Low-dose Antipsychotics in Children and Adolescent

Along with the field of adult psychiatry, antipsychotic agents are increasingly used in the field of child and adolescent psychiatry. Although neuroleptic malignant syndrome (NMS) and rhabdomyolysis are rare complication associated with antipsychotic agent, clinicians should need to pay attention to all potential adverse drug reaction (ADR). Also, ADRs in child and adolescent could show different signs and symptoms compared with those in adult. In this case report, we present a case of NMS in a child which occurred shortly after the resolution of rhabdomyolysis which was induced by low-dose risperidone.

Síndrome neuroléptico maligno con mielinolisis central pontina / Neuroleptic malignant syndrome with central pontine myelinolysis

RESUMEN El síndrome neuroléptico maligno (SNM) es una complicación severa de los antipsicóticos, en especial los de primera generación como el haloperidol, que fue el primero en el que se describió esta patología, caracterizada por fiebre, rigidez, alteración del estado de conciencia y disautonomías. Por otro lado, la mielinólisis central pontina (ahora llamada síndrome de desmielinización osmótica) resulta de las alteraciones agudas séricas del sodio, como las que ocurren en las reposiciones de hiponatremia, y podría poner en riesgo la vida al igual que el SNM. La asociación de estas dos patologías es inusual y hasta el momento no se conoce con claridad su relación causal, producto de los pocos casos reportados. Aunque se conoce la mortalidad del síndrome neuroléptico maligno, la compañía de la mielinolisis central pontina podría aumentar la morbimortalidad de esta entidad, por lo cual es necesario reconocerla rápidamente para prevenir la aparición de complicaciones, ya que no cuenta con un tratamiento específico. Presentamos el caso de un paciente joven que cursó con estas dos patologías, y consideramos que la causa de la mielinolisis central pontina fue el haloperidol, así como del SNM. A pesar de ello, este medicamento continúa siendo muy seguro en la práctica clínica ya que la aparición de estas complicaciones es una reacción idiosincrática por algún tipo de susceptibilidad genética desconocida.

SUMMARY Neuroleptic malignant syndrome (NMS) is a severe complication of antipsychotics, especially those of first generation such as haloperidol, which was the first in which this pathology was described, characterized by: fever, rigidity, alteration of the state of consciousness and dysautonomies. On the other side, central pontine myelinolysis (Now Called Osmotic Demyelination Syndrome), search results of acute sodium alterations of sodium, as those occurring in hyponatremia replenings and could put life at risk just like the NMS. The association of these two pathologies is unusual and until now, their causal relationship, the result of the few cases reported, is not clearly known. Although the relationship of the neurological syndrome may be limited, the company of central myelolysis could increase the morbidity of this entity, so it is necessary to be required quickly to prevent the onset of complications, which does not have a specific treatment. We present the case of a young patient who has these pathologies and we consider that the cause of centralized myelinolysis is haloperidol as well as NMS, despite this, this medication continues to be very safe in clinical practice since the appearance of These complications is an idiosyncratic reaction due to some type of unknown genetic susceptibility.

A Neuroleptic Malignant Syndrome Without Rigidity

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially lethal idiosyncratic reaction which may emerge in the aftermath of the treatments with neuroleptics demonstrating itself with the symptoms of altered consciousness, high fever, impaired autonomic functions, and muscle rigidity. Although various risk factors have been identified for NMS, its etiology is not completely known. The mortality and morbidity related with NMS could be reduced by early diagnosis, interruption of the neuroleptics used within a short period and aggressive treatment. Our case is different from general NMS cases due to lack of rigidity. A NMS case which developed within a short time in the aftermath of multiple antipsychotic use and wherein no rigidity was observed shall be discussed in this case report.

Síndrome Neuroléptico Maligno: a propósito de un caso clínico / Neuroleptic Malignant Syndrome: with regard to a case

Introducción: El síndrome neuroléptico maligno (SNM) es secundario al uso de neurolépticos en individuos susceptibles. Se presenta en una tétrada clínica: fiebre, rigidez muscular, cambios en el estado mental y disautonomía. Reacción idiosincrática rara pero potencialmente fatal. El síndrome aparece luego de iniciar neurolépticos típicos o atípicos en un rango de 4 a 14 días. Caso: Paciente de 20 años de edad, tratado inicialmente en una clínica psiquiátrica, donde ingresó debido a trastornos del comportamiento asociado al consumo de múltiples drogas psicotrópicas, especialmente marihuana y base de cocaína. Presentó un cuadro psicótico agudo, con alucinaciones auditivas, lenguaje incoherente, juicio alterado de la realidad. Sometido a cuatro sesiones de terapia electro-convulsiva (TEC) que empeoraron el cuadro clínico. Transferido al Servicio de Urgencias del Hospital Carlos Andrade Marín, donde ingresa en malas condiciones generales, con alteración del estado de conciencia, rigidez marcada, sialorrea, hipertermia, trastornos autonómicos, síntomas extrapiramidales, opistótonos y reflejos anormales. Discusión: Identificar el síndrome neuroléptico maligno es crítica para el inicio precoz del tratamiento y prevenir la muerte del paciente. El manejo incluye el uso de drogas dopaminérgicas como la bromocriptina, que reduce el bloqueo de la dopamina. Se utiliza conjuntamente dantrolene pero existe controversia al respecto. La amantadina incrementa la liberación presináptica de dopamina, y la levodopa/carbidopa incrementa los depósitos presinápticos de dopamina. Es crucial reponer la depleción de volumen, controlar la rigidez muscular y la hipertermia para evitar rabdomiolisis y falla renal.

Introduction: Neuroleptic malignant síndrome is caused by the use of neuroleptics in susceptible subjects. Cardinal features are: hyperthermia, severe muscular rigidity, changes in the level of consciousness and autonomic instability.The syndrome can depvelop shortly after the start of typical or atypical neuroleptics, often ranging between 4 to14 days. Case: A 20-year-old patient initially treated in a psychiatric hospital due to a mental disorder after using multiple psychotropic drugs, mainly marijuana and cocaine base. Having presented an acute psychotic episode with hallucinations, inconsistent language, reality distortion, the subject was treated with electroconvulsive therapy (ECT) which worsened his clinical condition. Then, he was transferred to the Emergency Service at Carlos Andrade Marin Hospital, where he was admitted in a poor general condition, marked rigidity, hyperthermia, lethargy, autonomic dysregulation, extrapyramidal symptoms, opistotonos and abnormal reflexes. Discusion: Neuroleptic syndrome identification is critical to start treatment and prevent death. Medications include dopaminergic drugs like bromocriptine that overcomes neuroleptic-induced dopaminergic blockade. It has also been used in combination with dantrolene though this approach remains controversial. Other agents include amantadine, which enhances presynaptic release of dopamine, and levodopa/carbidopa, which increase presynaptic dopamine stores. It is crucial to correct volume depletion, hyperthernia control and the muscle rigidity, as well as alkalinize the urine to avoid rhabdomyolisis and prevent renal failure.

Clozapine Induced Neuroleptic Malignant Syndrome / 대한구급학회지

Neuroleptic malignant syndrome is a rare, but potentially life-threatening adverse event associated with the use of neuroleptic agents. We describe the case of a 47-year-old schizophrenic woman who was treated with clozapine for years. The patient developed acute renal failure with pulmonary edema, and underwent mechanical ventilation and hemodialysis.

Progressive Encephalomyelitis with Rigidity and Myoclonus in an Intellectually Disabled Patient Mimicking Neuroleptic Malignant Syndrome

We present a case of 32-year-old male with profound mental retardation and autism spectrum disorder who had presented with seizures, rigidity and elevated creatine kinase and was initially diagnosed as neuroleptic malignant syndrome (NMS). The patient subsequently had a complicated clinical course, developing refractory status epilepticus, which lead to the eventual diagnosis of progressive encephalomyelitis with rigidity and myoclonus (PERM). We discuss the clinical similarities and differences between NMS and PERM, and highlight the need to consider alternative diagnoses when the clinical picture of NMS is atypical, particularly in this patient group where the history and clinical examination may be challenging.

Clozapine Induced Neuroleptic Malignant Syndrome / 대한중환자의학회지

Neuroleptic malignant syndrome is a rare, but potentially life-threatening adverse event associated with the use of neuroleptic agents. We describe the case of a 47-year-old schizophrenic woman who was treated with clozapine for years. The patient developed acute renal failure with pulmonary edema, and underwent mechanical ventilation and hemodialysis.

Neuroleptic Malignant Syndrome Associated with Valproate in an Adolescent

Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction that usually occurs after the administration of antipsychotic drugs. Antidepressants, benzodiazepines, and antiepileptic drugs are also suggested to be associated with NMS. It is believed to result from a dopaminergic blockade in the central nervous system. NMS is manifested by hyperthermia, muscle rigidity, autonomic dysfunction, altered mental status, leukocytosis, and elevated serum creatinine phosphokinase. Valproate is commonly used in the treatment of many psychiatric and neurologic disorders. Valproate can precipitate NMS, especially when used with antipsychotic drugs concurrently. A 17-year-old male patient, who presented with fever, muscular rigidity, confusion, sweating, and tachycardia was admitted to the emergency room. He had been taking only valproate for the last two months for bipolar disorder. His laboratory analyses revealed raised serum hepatic enzymes, creatinine phosphokinase, and myoglobin levels. Considering fever, rigidity, autonomic dysfunction, cognitive alteration, and high creatinine phosphokinase levels, the patient was diagnosed with NMS. In this paper, we aim to discuss the association between valproate and NMS.

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.

Malignant Neuroleptic Syndrome following Deep Brain Stimulation Surgery of Globus Pallidus Pars Internus in Cerebral Palsy / 대한구급학회지

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal outcome caused by sudden discontinuation or dose reduction of dopaminergic agents. We report an extremely rare case of NMS after deep brain stimulation (DBS) surgery in a cerebral palsy (CP) patient without the withdrawal of dopaminergic agents. A 19-year-old girl with CP was admitted for DBS due to medically refractory dystonia and rigidity. Dopaminergic agents were not stopped preoperatively. DBS was performed uneventfully under monitored anesthesia. Dopaminergic medication was continued during the postoperative period. She manifested spasticity and muscle rigidity, and was high fever resistant to anti-pyretic drugs at 2 h postoperative. At postoperative 20 h, she suffered cardiac arrest and expired, despite vigorous cardiopulmonary resuscitation. NMS should be considered for hyperthermia and severe spasticity in CP patients after DBS surgery, irrespective of continued dopaminergic medication.

Venous Thromboembolism Following Dantrolene Treatment for Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is one of the most severe iatrogenic emergencies in clinical service. The symptoms including sudden consciousness change, critical temperature elevation and electrolytes imbalance followed by mutli-organ system failure were common in NMS. In addition to aggressive interventions with intravenous fluid resuscitation and antipyretics, several antidotes have been suggested to prevent further progression of the muscle damage. Dantrolene has been reported to be one of the most effective treatments for NMS. However, the adverse effects of dantrolene treatment for NMS have not yet been evaluated thoroughly. Here we report a young male patient with bipolar I disorder who developed NMS after rapid tranquilization with haloperidol. Dantrolene was given intravenously for the treatment of NMS. However, fever accompanied with local tenderness, hardness with clear border and swelling with heat over the patient's left forearm occurred on the sixth day of dantrolene treatment. Venous thromboembolism (VTE) over intravenous indwelling site at the patient's forearm was noted and confirmed by Doppler ultrasound. The patient's VTE recovered after heparin and warfarin thrombolytic therapy. To our knowledge, this is the first case report demonstrating the possible relationship between dantrolene use and VTE in a patient with antipsychotic treatment. Although the causal relationship and the underlying pathogenesis require further studies, dantrolene should be used with caution for patients with NMS.

Malignant Neuroleptic Syndrome following Deep Brain Stimulation Surgery of Globus Pallidus Pars Internus in Cerebral Palsy / 대한중환자의학회지

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal outcome caused by sudden discontinuation or dose reduction of dopaminergic agents. We report an extremely rare case of NMS after deep brain stimulation (DBS) surgery in a cerebral palsy (CP) patient without the withdrawal of dopaminergic agents. A 19-year-old girl with CP was admitted for DBS due to medically refractory dystonia and rigidity. Dopaminergic agents were not stopped preoperatively. DBS was performed uneventfully under monitored anesthesia. Dopaminergic medication was continued during the postoperative period. She manifested spasticity and muscle rigidity, and was high fever resistant to anti-pyretic drugs at 2 h postoperative. At postoperative 20 h, she suffered cardiac arrest and expired, despite vigorous cardiopulmonary resuscitation. NMS should be considered for hyperthermia and severe spasticity in CP patients after DBS surgery, irrespective of continued dopaminergic medication.

Recurrent Idiopathic Catatonia: Implications beyond the Diagnostic and Statistical Manual of Mental Disorders 5th Edition

We describe a case of recurrent, life-threatening, catatonic stupor, without evidence of any associated medical, toxic or mental disorder. This case provides support for the inclusion of a separate category of "unspecified catatonia" in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) to be used to classify idiopathic cases, which appears to be consistent with Kahlbaum's concept of catatonia as a distinct disease state. But beyond the limited, cross-sectional, syndromal approach adopted in DSM-5, this case more importantly illustrates the prognostic and therapeutic significance of the longitudinal course of illness in differentiating cases of catatonia, which is better defined in the Wernicke-Kleist-Leonhard classification system. The importance of differentiating cases of catatonia is further supported by the efficacy of antipsychotics in treatment of this case, contrary to conventional guidelines.

Síndrome neuroléptico maligno-like como complicación en enfermedad de Parkinson: Desenlace fatal. Reporte de un caso y revisión de la literatura / Case report of an 80 year-old patient with Parkinson's Disease affected by Malignant Hyperthermia Syndrome with fatal outcome

Parkinson's disease presents its particular complications and others associated with pharmacological therapy. In this report we present an 80 year-old patient with Parkinson's disease, who having a febrile syndrome decides to suspend his usual antiparkinsonian treatment. As a consequence an exacerbation of their extrapyramidal symptoms appear and his fever syndrome persists without infectious focus. Neuroleptic Malignant Syndrome variant with fatal outcome was concluded.

La Enfermedad de Parkinson presenta complicaciones propias de su patología y asociadas a su terapia farmacológica. Presentamos un paciente de 80 años con Enfermedad de Parkinson, que debuta con un síndrome febril por lo que suspende su tratamiento antiparkinsoniano habitual. Como consecuencia, se agrega exacerbación de su clínica extrapiramidal, persistiendo su cuadro febril sin foco infeccioso. Se concluye variante del Síndrome Neuroléptico Maligno con resolución fatal.

Identificação e caracterização de interações medicamentosas em prescrições médicas da unidade de terapia intensiva de um hospital público da cidade de Feira de Santana, BA / Identification and characterization of drug interactions in prescriptions of the intensive care unit of a public hospital in the city of Feira de Santana, BA

OBJETIVOS E JUSTIFICATIVA: Identificar e caracterizar as interações medicamentosas presentes em prescrições médicas da Unidade de Terapia Intensiva (UTI) de um hospital público da cidade de Feira de Santana, Bahia. Uma vez que Interações medicamentosas (IM) representam fontes potencialmente remediáveis de erros na assistência e um risco para os pacientes. MÉTODOS: O estudo realizado foi do tipo descritivo. Após aprovação do Comitê de Ética em Pesquisa foram coletadas aleatoriamente 28 prescrições médicas da Unidade de Terapia Intensiva do hospital no ano de 2013, sendo necessário o preenchimento de uma ficha de coleta previamente estabelecida. Os dados coletados foram analisados pelo programa Micromedex® Drug Interactions, este caracterizou as interações medicamentosas segundo a gravidade e documentação comprobatória. RESULTADOS: Das 28 prescrições analisadas, 2 apresentaram nenhuma interação medicamentosa, enquanto 26 apresentaram alguma interações medicamentosas, resultando 99 potenciais interações medicamentosas, sendo os fármacos mais envolvidos: Midazolam, Ácido Acetilsalicílico, Fentanil e Dipirona. Interações medicamentoas mais frequentes foram: Fentanil + Mi­ dazolam; Dipirona + Enoxaparina; Midazolam + Omeprazol; Ácido Acetilsalicílico + Insulina Humana Regular. Segundo a gravidade foram encontradas: 5 contra Indicado, 31 maior, 58 moderado e 5 menor. 29 interações medicamentosas possuíam documentação excelente, 39 boa, 31 razoável e nenhuma com documentação desconhecida O uso, simultâneo de Fentanil + Midazolam pode resultar em depressão respiratória aditiva. Já o uso de Metoclopramida + Haloperidol pode aumentar o risco de reações extrapiramidais ou síndrome maligna dos neurolépticos. CONCLUSÃO: Confirmou­se que as interações medicamentosas são um problema frequente e cada vez mais relevante, pois identificá­las tornou­se um desafio para os profissionais de saúde...

BACKGROUND AND OBJECTIVE: To identify and characterize the Drug Interaction present in prescriptions of Intensive Care Unit (ICU) of a public hospital in the city of Feira de Santana, Bahia. Since, Drug Interaction (DI) represent potentially remediable sources of errors in care and a risk to patients. METHODS: The study was observational in nature. After approval by the Research Ethics Committee were randomly collected from 28 medical prescriptions in the Intensive Care Unit of the hospital in 2013, completing a previously established data collection form is required. The collected data were analyzed by ® Drug Interactions, Micromedex this program characterized the drug interaction according to the severity and supporting documentation. RESULTS: Of the 28 prescriptions analyzed, 2 showed no drug interaction, while 26 showed some drug interaction, resulting in 99 potential drug interactions being the drugs most involved: Midazolam, Acetylsalicylic Acid, Fentanyl and Dipyrone. Frequently drugs interactions were: Midazolam + Fentanyl; Dipyrone + Enoxaparin, Midazolam + Omeprazole, Acetylsalicylic Acid + Regular Human Insulin. According to severity were found: 5 against Indicated, 31 largest, 58 moderate and 5 smaller. 29 drug interaction had excellent documentation, 39 good, 31 fair, and none with unknown Using documentation, simultaneous Midazolam + Fentanyl may result in additive respiratory depression. Already using Metoclopramide + Haloperidol may increase the risk of extrapyramidal reactions or neuroleptic malignant syndrome. CONCLUSION: It was confirmed that the drug interaction is a frequent problem and increasingly relevant because identifying it became a challenge for health professionals...