Haloperidol
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Neuroleptic malignant syndrome in a patient with HHS: case report A 25-year-old man with hyperosmolar hyperglycaemic state (HHS) developed neuroleptic malignant syndrome during treatment with haloperidol and died [dosage and duration of treatment to reaction onset not stated], . The man, who had type 2 diabetes mellitus and schizophrenia with Munchausen syndrome, presented with hyperthermia and a decreased level of consciousness. His mother reported that over the last week he had stopped taking his diabetes medication and had consumed a large amount of candies and carbonated beverages. His regular medications were haloperidol metformin and biperiden; he continued taking only haloperidol. On admission, he had a rectal temperature 41.4°C, a BP of 108/60mm Hg and a pulse rate of 150. Physical examination showed that he was comatose with round, equal light-reactive pupils, severe muscle rigidity, flushed skin and dry mucous membranes. An ECG showed sinus tachycardia. Finger-prick blood sugar tests were beyond the measurement range. The man received normal saline and insulin and was cooled with wet sheets and ice packs. Laboratory tests revealed the following: WBC count 24 000/mm3, platelets 221 000 /mm3, haemoglobin 16.3 g/dL, glucose 880 mg/dL, osmolarity 380 mOsm/kg, creatinine 1.77 mg/dL, urea 59 mg/dL, ALT 45 IU/L, AST 65 IU/L, ALP 67 IU/L, creatine kinase (CK) 1770 IU/L, chloride 104 mmol/L, potassium 4 mmol/L, pH 7.37 and bicarbonate 22.7 mmol/L. Urine dipstick was positive for protein and haeme and urine was positive for myoglobin. He received cefuroxime and was admitted to an ICU. He regained consciousness, but his hyperthermia persisted. His CK level increased to 100 000 IU/L and his glucose level remained elevated; he had oliguria. The following day at 11am, he underwent placement of a femoral double lumen catheter for haemodiafiltration. However, later, his BP significantly decreased and he became unconscious. He received vasopressors, without any significant effect. He then developed treatment-refractory severe hyperkalaemia (9 mmol/L) and lactic acidosis. He developed ventricular fibrillation and received direct current shock. Continuous venovenous haemofiltration was started and pink ultrafiltrate was observed, indicating severe rhabdomyolysis. Decreased left ventricular function was observed by echocardiography. He received bromocriptine and vecuronium bromide. However, he did not respond to treatment and died at 7.15pm on the same day. His probable cause of death was considered to be multiorgan failure. Results of admission blood and urine cultures were found to be negative. Author comment: "[Neuroleptic malignant syndrome] is a severe condition affecting patients treated with neuroleptic agents of all classes that is made even worse when associated with HHS." Rock W, et al. Haloperidol-induced neuroleptic malignant syndrome complicated by hyperosmolar hyperglycemic state. American Journal of Emergency Medicine 801158058 27: 1018-e1-1018.e3, No. 8, Oct 2009 - Israel
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