• PDF / 124,687 Bytes
• 1 Pages / 623.591 x 841.847 pts Page_size
• 100 Downloads / 161 Views

DOWNLOAD

REPORT

---

1

S

Fatal neuroleptic malignant syndrome in an elderly patient: case report A 77-year-old man developed fatal neuroleptic malignant syndrome (NMS) during concomitant treatment with clozapine and paroxetine. The man was diagnosed with mild depression, progressive cognitive deterioration, memory impairment, psychotic behaviour and nocturnal wandering, and started receiving clozapine 50 mg/day. After 6 weeks, clozapine was replaced by paroxetine 20 mg/day due to inefficacy. After 3 weeks, clozapine was restarted at a dose of 25mg once daily at bedtime. Two days after clozapine initiation, he developed fever and confusion. He had rigidity and intermittent generalised tonic contractions of his trunk and limb muscles. He was subsequently hospitalised with a 1-week history of fever (≤ 40°C), confusion, muscle pain and severe rigidity. On admission, he was mute and unresponsive to verbal commands and had intermittent bouts of agitation and incoherent speech. His limbs tightened occasionally and assumed a fixed extension posture. An examination revealed a temperature of 39.7°C, tachypnoea (≤ 40 respiration/min) and a HR of 110/min; his BP fluctuated between 130/70 and 100/50mm Hg. Laboratory investigations showed a WBC count of 9.6 × 109/L (range 4.1–9.8) and severe hyperglycaemia (482 mg/dL); he had a hyperosmolar nonketotic syndrome with a serum sodium level of 161 mEq/L and an osmolality of 395 mOsm/kg. Arterial blood gas analysis showed metabolic acidosis with an oxygen partial pressure of 65.2mm Hg, a CO2 partial pressure of 35mm Hg, a pH of 7.55 and a bicarbonate level of 30.9mmol. He was transferred to a geriatric ICU. Clozapine and paroxetine were immediately discontinued and the man started receiving IV fluids, insulin and antibacterials. A brain CT scan showed a pattern of subcortical and cortical atrophy. Awake EEG findings showed minimal nonspecific generalised slow waves. By hospital day 3, his serum creatine kinase (CK) level had increased to 979 U/L (normal 30–170). He was diagnosed with NMS and started receiving continuous SC apomorphine injection and domperidone. His clinical condition improved rapidly, with decreased muscle tone and contraction frequency; he became more responsive and less agitated. However, his elevated CK levels and axial rigidity persisted and, by hospital day 6, he had developed severe respiratory insufficiency, renal failure and coagulation disorder. He had a creatinine level of 4 mg/dL, a blood urea nitrogen level of 140 mg/dL, a prothrombin time of 21.8 seconds and a platelet level of 90 000mm3. On hospital day 11, he died from cardio-respiratory arrest. An autopsy showed that the man’s NMS had been complicated by disseminated intravascular coagulation and aspiration pneumonia. Gambassi G, et al. Fatal neuroleptic malignant syndrome in a previously long-term user of clozapine following its reintroduction in combination with paroxetine. Aging Clinical and Experimental Research 18: 266-270, No. 3, Jun 2006 801044283 Italy

0114-9954/10/1117-0001/$14.95 Adis © 2010 Springer Internati