Antipsychotics
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Neuroleptic malignant syndrome: case report A 44-year-old woman developed neuroleptic malignant syndrome during antipsychotic treatment with haloperidol, promazine, chlorpromazine, aripiprazole, clozapine, sodium valproate and valproic acid for bipolar disorder [not all routes stated]. The woman had been diagnosed with bipolar disorder with psychotic features at the age of 17 years. Over the years, she had been treated with mood stabilisers like valproic acid, lithium and carbamazepine, first generation antipsychotics like thioridazine, chlorpromazine, haloperidol and clotiapine, second generation antipsychotics like quetiapine and risperidone and unspecified benzodiazepines, with a poor success on preventing relapses. In 2005, she was switched to clozapine [Leponex] 200mg daily, and showed a moderate functional improvement and a good psychopathological stability for many years. In December 2017, she started using generic clozapine due to unavailability of the branded product. Thereafter, her family reported gradual onset of various and worsening symptoms. In September 2018, she was admitted with a 2-month history of severe psychomotor agitation, aggression, hyperactivity, oppositional and inappropriate behaviour. For first two days in the emergency unit, she received therapies as needed comprising sodium valproate 400mg plus IV delorazepam 2mg, haloperidol 5mg plus IM delorazepam 2mg, IM promazine 25mg, IM aripiprazole 9.75mg plus IM lorazepam 4mg. Upon admission, she was treated with IM aripiprazole 9.75mg twice daily and IM lorazepam 4mg three times daily. Then, aripiprazole injections were discontinued and switched to aripiprazole 30mg tablets once daily along with addition of clozapine 150mg daily and IV valproic acid 400mg once daily. Additionally, she received oral chlorpromazine 100mg. The duration for which she was receiving clozapine at home can not be confirmed. She was physically restrained due to the persistence of agitation and oppositional symptomatology along with severe thought and behavioural disorganisation, delusions, auditory allucinations and self-injurious behaviour started at hospitalisation day 2. On the second day of treatment, she developed fever up to 38.1°C, 37.8°C during the third day and between 37.2 and 37.7°C during the further 20 days. Negative results of urine culture test, chest X-ray and a pneumology visit excluded infections. However, she received an antibiotic therapy with ceftriaxone. A significant increase in creatine phosphokinase (CPK) blood levels was noted from day 4. Additionally, her RBC count increased with an elevation of myoglobin and LDH. On the sixth day, she experienced severe dysphagia, requiring insertion of a nasogastric tube for both feeding and therapy administration. Additionally, she developed multiple other medical conditions including pressure lability, tachycardia, diaphoresis and seborrhoea. After 6 days from the admission, she started to alternate between hypoactivity, agitation, motor slowing, sedation and violent outbursts. She appeared increas
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