Cases That Test Your Skills

When treatment spells trouble

Current Psychiatry. 2005 April;4(4):92-100

References

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5. Mann SC, Caroff SN, Keck PE, Jr, et al. Neuroleptic malignant syndrome. In: Mann SC, Caroff SN, Keck PE Jr, et al. Neuroleptic malignant syndrome and related conditions (2nd ed). Washington, DC: American Psychiatric Association; 2003;1:44.-

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CONTINUED TREATMENT: A RELAPSE

Three months later, Ms. G is readmitted to the neurology service for 3 weeks after being diagnosed with elevated CK, possibly caused by NMS or rhabdomyolysis secondary to persistent dyskinesia. We believe an inadvertent decrease in her carbidopa/levodopa caused the episode, as she had taken no neuroleptics between hospitalizations.

Ms. G is discharged on quetiapine, 25 mg nightly, along with her other medications. Her current psychiatric and neurologic status is unknown.

The authors’ observations

Detecting NMS symptoms early is critical to preventing mortality. Although NMS risk with atypical and typical antipsychotics is similar,⁴ fewer deaths from NMS have been reported after use of atypicals (3 deaths among 68 cases) than typical neuroleptics (30% mortality rate in the 1960s and 70s, and 10% mortality from 1980-87).¹⁴ Earlier recognition and treatment may be decreasing NMS-related mortality.⁴

Consider NMS in the differential diagnosis when the patient’s mental status changes.

Related resources

Emedicine: Neuroleptic malignant syndrome. www.emedicine.com/med/topic2614.htm.
Bhanushali MJ, Tuite PJ. The evaluation and management of patients with neuroleptic malignant syndrome. Neurol Clin 2004;22:389-411.
Susman VL. Clinical management of neuroleptic malignant syndrome. Psychiatr Q 2001;72:325-36.

Drug brand names

Amoxicillin/clavulanate • Augmentin
Aripiprazole • Abilify
Carbidopa/levodopa • Sinemet
Chlorpromazine • Thorazine
Citalopram • Celexa
Clozapine • Clozaril
Lopressor • Toprol
Lorazepam • Ativan
Olanzapine • Zyprexa
Pramipexole • Mirapex
Quetiapine • Seroquel
Risperidone • Risperdal
Tolterodine • Detrol
Trazodone • Desyrel
Ziprasidone • Geodon

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgments

The authors wish to thank Robert B. Milstein, MD, PhD, and Benjamin Zigun, MD, JD, for their help in preparing this article for publication.

This project is supported by funds from the Division of State, Community, and Public Health, Bureau of Health Professions (BHPr), Health Resources and Services Administration (HSRA), Department of Health and Human Services (DHHS) under grant number 1 K01 HP 00071-02 and Geriatric Academic Career Award ($58,009). The content and conclusion are those of Dr. Tampi and are not the official position or policy of, nor should be any endorsements be inferred by, the Bureau of Health Professions, HRSA, DHHS or the United States Government.

When treatment spells trouble

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