The neuroleptic malignant syndrome: a logical approach to the patient with temperature and rigidity.

The neuroleptic malignant syndrome is a rare, potentially fatal, adverse reaction to neuroleptic drugs characterised by severe rigidity, high temperature and autonomic dysfunction. In the light of the hypothesized pathophysiology of this condition, a rational approach to the management of patients presenting with temperature and rigidity is provided. The aims of this approach are three-fold: to reduce the incidence of the condition, to be able to recognise it early so as to treat before life-threatening complications arise, and to be able to recognise early those conditions which mimic neuroleptic malignant syndrome, so as not to delay their specific treatment.

Hospitalization of adults for asthma and inhaled corticosteroid use in an island population.

Inhaled corticosteroids have been shown to reduce morbidity and the need for hospitalization from asthma. Despite improvements in the therapy of asthma, epidemiologic data from several countries has shown that the hospital admission rates for asthma among adults at a population level are on the increase. The prevalence rate of hospital admission for asthma among Maltese adults aged 15-59 years was determined retrospectively from 1989 to 1993. Concurrent yearly total dispensal of inhaled corticosteroids for the whole population was also calculated. This study was undertaken amongst a well-defined island population served by a single medical facility offering emergency services, and a possible association between these two trends was investigated by means of logistic regression. The age-specific hospital admission rates for asthma decreased from 96.2 (95% CI: 109.7, 82.7) per 100,000 in 1989 to 38.1 (95% CI: 46.4, 29.8) per 100,000 in 1993. The prevalence rates of admission from asthma decreased from 67.6 (95% CI: 78.9, 56.3) per 100,000 in 1989 to 30.6 (95% CI: 38.0, 23.2) per 100,000 in 1993. The dispensal of inhaled beclomethasone dipropionate (BDP) increased from 0.99 defined daily dose (DDD) per 1000 population in 1989 to 3.28 DDD per 1000 in 1993. Logistic regression showed that increasing dispensal of inhaled BDP by 1 DDD per 1000 decreased the odds of an admission from asthma to 0.71 (95% CI: 0.65, 0.78) times their previous value. Similarly, the odds of an individual being hospitalized because of asthma decreased to 0.75 (95% CI: 0.67, 0.83) times their previous value. This study concludes that there was a progressive decrease in hospital admission rates for asthma in adults, and this trend correlates well with increasing use of inhaled corticosteroids at a community level. This must, however, be interpreted with care in light of the fact that increase in utilization of anti-inflammatory therapy probably also reflected improved general and widespread care for asthma.

Carbon monoxide poisoning: easy to treat but difficult to recognise.

Carbon monoxide (CO) poisoning is a common medical emergency and a frequent cause of deliberate or accidental death. It can cause acute and chronic central nervous system damage which may be minimised by prompt treatment with 100% oxygen or hyperbaric oxygen therapy. However, recognition of this intoxication can be difficult. Failure to diagnose it may have disastrous effects on the patient, and other members of the household who could subsequently become intoxicated. Guidance on the correct diagnosis of this condition is provided in the light of a number of studies screening emergency room populations. Guidelines for treatment with hyperbaric oxygen therapy are also reviewed.

Paradoxical autonomic response to procyclidine in the neuroleptic malignant syndrome.

BACKGROUND: Neuroleptic Malignant Syndrome (NMS) is an adverse reaction to dopamine receptor antagonists, characterised by hyperpyrexia, extrapyramidal rigidity and impaired autonomic function. It might result from central dopamine receptor blockade that causes severe muscle contraction. METHOD: Case Study. RESULTS: High dose intravenous therapy with the anticholinergic drug, procyclidine hydrochloride, temporarily diminished the muscle rigidity and reversed most of the autonomic features in a patient with NMS occurring after a single intramuscular dose of the dopamine antagonist metoclopramide. Paradoxically, however, the heart rate decreased and bowel movements increased with this atropine-like drug. CONCLUSION: Since the degree of tachypnoea, tachycardia, and bowel hypotonia closely paralleled the severity of the muscle rigidity, it is suggested that these autonomic features of NMS result from sustained muscle contraction rather than a direct effect of neuroleptic drugs on the central nervous system.

Unstable angina and exposure to carbon monoxide.

Inhalation of small amounts of carbon monoxide diminishes the pain threshold in patients with stable angina pectoris. The aim of this study was to identify and describe patients who had been exposed unknowingly to toxic inhalations of this gas and subsequently presented to hospital with a clinical picture of unstable angina. Blood carboxyhaemoglobin levels of 104 patients referred with unstable angina to a coronary care unit were determined on admission. The likely source of carbon monoxide was identified in all patients. Three patients had definite carbon monoxide intoxication. Another five patients had evidence of minor exposure. When the three cases with carbon monoxide poisoning were excluded, the mean carboxyhaemoglobin level was 2.5% (+/- 1.3) for smokers (n = 30) and 0.6% (+/- 0.5) for non-smokers (n = 71). Use of fossil fuel combustion in an enclosed environment was responsible for the three most serious intoxications and one of the minor cases. We suggest that a number of patients admitted for coronary care with unstable angina may have significant carbon monoxide poisoning. This intoxication is often overlooked by attending physicians with the result that high concentration oxygen therapy is not administered, when it is in fact a necessary part of treatment.

Intestinal infarction following carbon monoxide poisoning.

A 65 year old patient admitted with carbon monoxide poisoning developed acute pulmonary oedema during treatment with hyperbaric oxygen. After initial recovery he developed extensive intestinal ischaemia which rapidly led to death. It is suggested that intestinal vasoconstriction due to left ventricular failure made the gut much more vulnerable to the hypoxic effects of carbon monoxide than the brain and heart.

Neuroleptic malignant syndrome presenting as hyperosmolar non-ketotic diabetic coma.

A 50-year-old man presented with hyperosmolar non-ketotic diabetic coma associated with the neuroleptic malignant syndrome (NMS) after intramuscular treatment with haloperidol. It is suggested that NMS may occur as a complication of uncontrolled diabetes mellitus with dehydration. Conversely, NMS might precipitate diabetic coma in patients with previously well controlled blood glucose.