Neuroleptic Malignant Syndrome

DSM-IV criteria for the diagnosis of neuroleptic malignant syndrome (NMS) include elevated temperature with muscular rigidity accompanied by two or more of the following: diaphoresis, dysphagia, tremor, incontinence, altered consciousness, tachycardia, blood pressure changes, leukocytosis, or elevated creatine kinase. It usually occurs 3 to 9 days after initiation of neuroleptic therapy or addition of second neuroleptic medication.

Precipitants

• Neuroleptic drug use (phenothiazines, butyrophenones, thioxanthenes)
• Withdrawal of dopaminergic stimulants in Parkinson's disease (amantadine, levodopa/carbidopa, bromocriptine)
• Dopamine antagonist use (metoclopramide, tetrabenazine, promethazine, prochlorperazine, amoxapine, reserpine, droperidol)
• Lithium combined with clozapine, carbamazepine, phenelzine, chlorpromazine, doxepin
• Tetracyclic antidepressants
• Monoamine oxidase inhibitors

Causes

• Several factors such as included evomepromazine, Haloperidol, Thioridazine, Trifluperidol, Pipothiazine that may cause Neuroleptic Malignant Syndrome.
• Neuroleptic malignant syndrome may also occurs due to interference with dopamine activity in the central nervous system. Dopamine receptor blockade is considered the cause of NMS. Because the blockade of dopamine in the striatum can cause rigidity, tremor, and rhabdomyolysis.

Symptoms

• Elevated temperature +++++ (by definition)
• Rigidity +++++
• Dyspnea ++
• Tremor ++
• Urinary incontinence
• Dysphagia
• Diaphoresis
• Drowsiness
• Confusion
• Agitation

Signs

Tetrad:

• Elevated temperature (usually 38.5° to 42° C)
• Rigidity (classic lead pipe, which may be localized, trismus, masked facies ++, and dyskinesia)
• Altered level of consciousness (from confusion and agitation to lethargy, stupor, coma ++, and mutism +++)
• Autonomic dysfunction (tachycardia ++++, labile blood pressure +++, diaphoresis +++, tachypnea +++, hyperreflexia ++, pallor, and dysrhythmias/cardiac arrest).

Treatment

• Several treatments for Neuroleptic Malignant Syndrome such as includes, Emergency intensive care, Discontinue medications causing the reaction, Fever treatments, Muscle relaxant, Dopaminergic drugs.
• Electroconvulsive therapy (ECT) has been used to treat NMS. It can help with the alteration of temperature, level of consciousness and diaphoresis. Electroconvulsive therapy (ECT) may also be useful in treating the underlying psychiatric disease in patients who are unable to take neuroleptics.