An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic

AIMS: Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening complication of antipsychotic medication. There are no gold standard tests to diagnose NMS, however various diagnostic criteria have been suggested. NMS is typically reported in patients who have recently commenced an antipsychot...

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Autores principales: Sanger, Emily, Rutt, Benjamin, Hall, David, Foster, Harry, Obasohan, Owen
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cambridge University Press 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10345618/
http://dx.doi.org/10.1192/bjo.2023.357
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author Sanger, Emily
Rutt, Benjamin
Hall, David
Foster, Harry
Obasohan, Owen
author_facet Sanger, Emily
Rutt, Benjamin
Hall, David
Foster, Harry
Obasohan, Owen
author_sort Sanger, Emily
collection PubMed
description AIMS: Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening complication of antipsychotic medication. There are no gold standard tests to diagnose NMS, however various diagnostic criteria have been suggested. NMS is typically reported in patients who have recently commenced an antipsychotic or had a change in dose. This case report describes an elderly female who developed NMS after being treated with the same dose of antipsychotic for 7 years. We aimed to establish whether similar cases are commonly reported, and what the key learning outcomes are. METHODS: This case presents an 82-year-old female taking the same dose of zuclopenthixol for 7 years. She was admitted with increased confusion and was initially prescribed antibiotics for a possible infection. She later became pyrexial and developed hypertonia, at which point NMS was suspected. Her creatinine kinase titre was significantly elevated, and her antipsychotic was discontinued. A potential trigger was a significant rectal bleed occurring a few weeks prior with no other obvious triggers noted. She was switched to quetiapine but developed NMS again when this dose was increased. RESULTS: There are few reports of NMS occurring in patients taking a long-term and stable antipsychotic dose. One case describes NMS developing after 30 years on Clozapine with no clear trigger. Another reports NMS after 7 years on Olanzapine, however this was triggered by dehydration. This case is an example of NMS in an elderly patient with a complex medical history who was initially misdiagnosed with sepsis before NMS was suspected. This shows the importance of considering NMS not only in those who have recently commenced antipsychotics or recently changed dose, but also those who have been stable on medication for a number of years. In suspected NMS, we should aim to stop relevant medication immediately and commence conservative management. It is important to highlight these atypical presentations so that NMS can be recognised without delaying treatment, thereby reducing mortality and improving patient outcomes CONCLUSION: This report highlights the importance of considering NMS in patients who have been prescribed the same dose of antipsychotic for an extended period. Awareness of potential risk factors such as medical comorbidity that may trigger an episode of NMS even in those on established antipsychotic treatment is vital. Symptoms may mimic infection and it is important to raise awareness of atypical presentations to effectively identify, and treat, NMS earlier to improve outcomes.
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spelling pubmed-103456182023-07-15 An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic Sanger, Emily Rutt, Benjamin Hall, David Foster, Harry Obasohan, Owen BJPsych Open Case Study AIMS: Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening complication of antipsychotic medication. There are no gold standard tests to diagnose NMS, however various diagnostic criteria have been suggested. NMS is typically reported in patients who have recently commenced an antipsychotic or had a change in dose. This case report describes an elderly female who developed NMS after being treated with the same dose of antipsychotic for 7 years. We aimed to establish whether similar cases are commonly reported, and what the key learning outcomes are. METHODS: This case presents an 82-year-old female taking the same dose of zuclopenthixol for 7 years. She was admitted with increased confusion and was initially prescribed antibiotics for a possible infection. She later became pyrexial and developed hypertonia, at which point NMS was suspected. Her creatinine kinase titre was significantly elevated, and her antipsychotic was discontinued. A potential trigger was a significant rectal bleed occurring a few weeks prior with no other obvious triggers noted. She was switched to quetiapine but developed NMS again when this dose was increased. RESULTS: There are few reports of NMS occurring in patients taking a long-term and stable antipsychotic dose. One case describes NMS developing after 30 years on Clozapine with no clear trigger. Another reports NMS after 7 years on Olanzapine, however this was triggered by dehydration. This case is an example of NMS in an elderly patient with a complex medical history who was initially misdiagnosed with sepsis before NMS was suspected. This shows the importance of considering NMS not only in those who have recently commenced antipsychotics or recently changed dose, but also those who have been stable on medication for a number of years. In suspected NMS, we should aim to stop relevant medication immediately and commence conservative management. It is important to highlight these atypical presentations so that NMS can be recognised without delaying treatment, thereby reducing mortality and improving patient outcomes CONCLUSION: This report highlights the importance of considering NMS in patients who have been prescribed the same dose of antipsychotic for an extended period. Awareness of potential risk factors such as medical comorbidity that may trigger an episode of NMS even in those on established antipsychotic treatment is vital. Symptoms may mimic infection and it is important to raise awareness of atypical presentations to effectively identify, and treat, NMS earlier to improve outcomes. Cambridge University Press 2023-07-07 /pmc/articles/PMC10345618/ http://dx.doi.org/10.1192/bjo.2023.357 Text en © The Author(s) 2023 https://creativecommons.org/licenses/by-nc/4.0/This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. This does not need to be placed under each abstract, just each page is fine.
spellingShingle Case Study
Sanger, Emily
Rutt, Benjamin
Hall, David
Foster, Harry
Obasohan, Owen
An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic
title An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic
title_full An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic
title_fullStr An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic
title_full_unstemmed An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic
title_short An Unusual Case of Neuroleptic Malignant Syndrome on a Stable Dose of Antipsychotic
title_sort unusual case of neuroleptic malignant syndrome on a stable dose of antipsychotic
topic Case Study
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10345618/
http://dx.doi.org/10.1192/bjo.2023.357
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