Cases That Test Your Skills

‘Scared’ and short of breath

Current Psychiatry. 2011 September;10(9):75-83

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With the broad application of atypical antipsychotics, physicians should be aware of atypical NMS presentation. Although NMS diagnosis commonly requires core symptoms of hyperthermia and muscle rigidity (Table 1 and 2),³¹ atypical presentations may not demonstrate temperature changes and/or muscle rigidity or may progress slowly over several days, leading to a delay in diagnosis and treatment.^28,30,32,33 Therefore, clinicians should evaluate any patient taking antipsychotics for features of NMS and not prematurely exclude a NMS diagnosis in cases where severe rigidity or hyperthermia is not initially apparent.³³

Table 1

DSM-IV-TR criteria for neuroleptic malignant syndrome

A. The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
B. 2 (or more) of the following:
diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leukocytosis laboratory evidence of muscle injury eg, elevated creatine kinase)
Source: Reference 31

Table 2

Diagnostic features of neuroleptic malignant syndrome

Essential features: severe muscle rigidity and elevated temperature in an individual using neuroleptic medication
Elevated temperature: from mild (eg, 99º to 100ºF) to markedly hyperthermic states (eg, 106ºF)
Creatine kinase: typically elevated, ranging from minor elevations to extremely high levels (exceeding 16,000 IU)
Other features: mental status changes, unstable blood pressure, diaphoresis, other signs of autonomic dysfunction
Source: Reference 31

Related Resource

Neuroleptic Malignant Syndrome Information Service. www.nmsis.org.

Drug Brand Names

Amantadine • Symmetrel
Aripiprazole • Abilify
Benztropine • Cogentin
Bromocriptine • Parlodel
Clozapine • Clozaril
Dantrolene • Dantrium
Diphenhydramine • Benadryl
Enoxaparin • Lovenox
Fosphenytoin • Cerebyx
Haloperidol • Haldol
Hydroxyzine • Vistaril
Levodopa • Sinemet
Lithium • Eskalith, Lithobid, others
Lorazepam • Ativan
Olanzapine • Zyprexa
Paliperidone • Invega
Pantoprazole • Protonix
Phenytoin • Dilantin
Quetiapine • Seroquel
Risperidone • Risperdal
Trazodone • Desyrel, Oleptro
Valproic acid • Depakote
Warfarin • Coumadin
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.

Acknowledgements

The authors are very grateful for the critical reviews by James R. Allen, MD, MPH, professor of Child and Adolescent Psychiatry Fellowship Program at the University of Oklahoma and Lori Hake, DO, director of Psychiatry Residency Training Program at Griffin Memorial Hospital in Norman, OK.