Lamotrigine, quetiapine and aripiprazole-induced neuroleptic malignant syndrome in a patient with renal failure caused by lithium: a case report

BACKGROUND: Neuroleptic malignant syndrome (NMS) may be induced by atypical antipsychotic drugs (AAPDs) such as aripiprazole, olanzapine, risperidone and quetiapine, either as a single treatment or in combination with other drugs. A case of NMS following the administration of lamotrigine, aripiprazole and quetiapine in a patient with bipolar disorder, and with renal failure caused by toxic lithium levels has not been reported. CASE PRESENTATION: A 51-year-old female patient with a 27-year history of bipolar disorder, being treated with lithium, fluoxetine, olanzapine, gabapentine, perazine and biperiden, was admitted to the hospital due to depressed mood and delusions. A urinary tract infection was diagnosed and antibiotic therapy was initiated. After 5 days of treatment her physical state deteriorated and she developed a fever of 38.4 °C. Her laboratory results revealed a toxic level of lithium (2.34 mmol/l). Acute renal failure was diagnosed and the lithium was withdrawn. After stabilization of her condition, and despite her antipsychotic treatment, further intensification of delusions and depressed mood were observed. All drugs being taken by the patient were withdrawn and lamotrigine and aripiprazole were initiated. Due to the insufficient effectiveness of aripiprazole treatment and because of problems with sleep, quetiapine was added, however further treatment with this drug combination and an increase of quetiapine to 400 mg/d eventually caused NMS. Amantadine, lorazepam and bromocriptine were therefore initiated and the patient’s condition improved. CONCLUSION: This case report indicates that concurrent use of multiple antipsychotic drugs in combination with mood stabilizers in patients with organic disorders confers an increased risk of NMS development.