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Glycopyrrolate/nitrazepam/metoclopramide Neuroleptic malignant syndrome and serotonin syndrome: case report

A 19-month-old boy developed neuroleptic malignant syndrome and serotonin syndrome following treatment with metoclopramide. Additionally, glycopyrrolate and nitrazepam also contributed to the development of neuroleptic malignant syndrome [not all indications stated]. The boy, who had encephalopathy and spastic quadriplegia due to severe birth anoxia was admitted to the hospital for a gastrostomy change. He was born at the gestational age of 41+1/7 weeks via induced delivery and his birth weight was 3.4kg and an Agpar score was 2–1–0. He developed a chronic respiratory insufficiency and it was suspected that the respiratory insufficiency was secondary to chronic lung aspiration. He underwent gastrojejunal tube replacement and discharged from hospital. Two weeks after the discharge, he started receiving oral metoclopramide 0.1 mg/kg/dose 3 times a day due to poor gavage tolerance and no weight gain was noted. Meanwhile, he developed irritability and agitation. Therefore, the boy’s treatment with metoclopramide was suspended after 6 doses. This led to improvement in irritability and agitation. Five days later, he resumed on metoclopramide and the frequency of metoclopramide was increased to 4 times a day. However, he developed intermittent fever over the next 2 weeks and his irritability had recurred. Due to intermittent fever and irritability, the paediatrician consultation was obtained and he was again hospitalised due to pneumonia associated with fever, tachypnoea and tachycardia. He developed new severe spasticity and spontaneous tremors. Impaired consciousness was also noted. Upon further investigation it was observed that he was receiving oral metoclopramide 4 times a day, oral glycopyrrolate 500mcg 3 times a day, amoxicillin/clavulanic-acid, ranitidine, oral nitrazepam 1mg twice a day, amlodipine and colecalciferol [vitamin D3] prior to the hospitalisation. Thereafter, he was transferred to paediatric ICU and treated with salbutamol, calcium gluconate, oxygen, dexmedetomidine, piperacillin/tazobactam, cefotaxime and vancomycin. His lab test showed highly increased levels of troponin I and creatine kinase. Hence, myocarditis was suspected. His liver function tests revealed increase in the AST and ALT levels. Meanwhile, he developed respiratory failure that required intubation. He received inotropes due to transient cardiovascular instability and his treatment with metoclopramide was discontinued. Potassium chloride was also given on day 1 of the hospitalisation. Despite intubation, he experienced multiple episodes of acute desaturation along with spontaneous clonus, tremors and important rigidity. Hence, dantrolene was initiated that led to resolution of the rigidity. Additionally, he was treated with dexamethasone, furosemide and glycopyrrolate on day 2 of the hospitalisation. However, he had continued hyperreflexia and hypertonia. Levetiracetam, midazolam and propofol was given. Gradually, his crea