Neuroleptic Malignant Syndrome: Symptoms and Treatment

Neuroleptic malignant syndrome is a rare but a serious condition. This condition represents a neurological emergency in most cases.  This syndrome is characterized by- rigidity, hyperthermia and autonomic dysregulation which can occur as a complication when anti psychotic drugs are used. It occurs in about 0.5 to 1% of people exposed to neuroleptics. There are certain anti psychotic drugs which can cause neuroleptic malignant syndrome such as olanzapine, amisulpride etc.

Clozapine had lesser risk in developing tremors and rigidity. This syndrome has been associated with drugs that lead to decreased dopamine receptor activation.

Neuroleptic malignant syndrome is characterized by a triad of symptoms:

-fever

-rigidity

-cognitive changes

The clinical features of neuroleptic malignant syndrome include the following:

-pallor

-dyspnea

-tremors

-tachycardia

-diaphoresis

-labile blood pressure

-hyperthermia

-lethargy, stupor, coma

-psychomotor agitation

-dysphagia

 

Diagnosis:

There is no such diagnostic test available for the neuroleptic malignant syndrome but testing is crucial in evaluation of patients who are at a risk of developing this syndrome. To confirm the clinical symptoms, laboratory diagnosis is necessary.

The laboratory diagnosis will show an elevated level of serum creatine kinase (ck). In neuroleptic malignant syndrome the ck level may vary from 1000 IU/L to 100,1000IU/L. Normal ck level is seen at the early onset of the syndrome or in conditions when rigidity is not present.

Treatment:

The treatment starts with discontinue of all the antipsychotic drugs. Symptoms of neuroleptic malignant syndrome usually disappear with 2 weeks. If the syndrome is caused by the long acting injections of antipsychotics then the symptoms can last for as long as a month.

In the treatment of this syndrome supportive treatment should be used extensively. These supportive measures are aimed at preventing further complications and maintaining all the organ functions.

-patient should be given proper circulatory and ventilator support as needed.

-antipyretics should be used to control body temperature.

-aggressive fluid resuscitation and alkalization of urine can prevent the occurance of kidney failure.

Electroconvulsive therapy is said to be effective in managing patients with neuroleptic malignant syndrome.

Drug therapies with amantadine, bromocriptine and dantrolene with electroconvulsive therapy are said to be useful in the treatment of this syndrome.

Dantrolene is a sketal muscle relaxant, which is also effective in the treatment of malignant hyperthermia.

Bromocriptine is a dopamine antagonist. It is generally recommended to continue this drug for 10 days post the occurance of the episode and it may then be gradually tapered.

Amantadine is generally used as an alternative to bromocriptine. Amantadine has anticolinergic and dopaminergic effect.

 

Complications:

-renal failure

-cardiac arrest

-respiratory failure

-dehydration

-seizure

-hepatic failure

-infections

-pulmonary embolisms

-uncontrolled psychosis

 

Prognosis:

 

This syndrome shows a mortality rate of 10-20%. Mortality rates are seen more in people who develop severe muscle necrosis which results in rhabdomyolysis.

People who have developed neuroleptic malignant syndrome before are at a higher risk of developing the syndrome again.

If antipsychotic drug therapy is started again within 2 weeks of the occurance of this episode then there is a much higher chance of recurrence of this syndrome.

However 30% will still have recurrence even after 2 weeks from the occurance of the episode.

Most people who have suffered from this syndrome are able to tolerate another antipsychotic drug anytime in the future.

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