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Neuroleptic malignant syndrome followed by malignant catatonia: case report A 27-year-old man developed neuroleptic malignant syndrome (NMS) followed by malignant catatonia during antipsychotic treatment with haloperidol and quetiapine [routes and dosages not stated; durations of treatments to reactions onsets not stated]. The man had medical history of resection of dysembryplastic neuroepithelial tumour in 2000 and 2006, hypothyroidism, seizure disorder, autism spectrum disorder, unspecified mood disorder and mental retardation. He was residing in a group home. He was admitted for the treatment of aggressive behaviours. During admission, he started receiving haloperidol in addition to his previous medications including buspirone, clonidine, valproic acid, fluvoxamine, oxcarbazepine, quetiapine and trazodone. Within a few days, he became confused and drowsy, and exhibited high fever. Investigations showed leucocytosis and increased creatine phosphokinase (CPK). His brain MRI and EEG were normal. He was diagnosed with aspiration pneumonia. He was treated with unspecified antibiotics. However, his CPK levels continued to increase. Owing to the recent exposure to two different antipsychotics (haloperidol and quetiapine) along with rigidity, fever and CPK elevation, diagnosis of NMS was considered. The man started recieving treatment with dantrolene. Over the period of next 2 days, the CPK levels began to drop. The leucocytosis and fever resolved. Then antibiotics were discontinued. Soon thereafter, he began to develop immobility, mutism, negativism and staring. These symptoms were compatible with malignant catatonia. Based on the findings of MRI, EEG and lumbar puncture the possibilities of tumour recurrence, seizures and CSF infection were ruled out, and he was diagnosed with malignant catatonia. He was treated with clonazepam, but it did not improve the symptoms. Therefore, he was started on electroconvulsive therapy (ECT). His catatonia symptoms started to improve following second ECT session. He became more verbal, with less staring and decreased negativism. Following fifth ECT session, he returned to his baseline level and was able to perform activities of daily living. Later, quetiapine was restarted at low doses and was subsequently up-titrated to control his behaviours. The man was monitored for NMS or catatonic symptoms. Author comment: "Any antipsychotic drug, including the atypicals, can cause NMS. NMS is an idiosyncratic response to dopamine receptor antagonist medications." "In this case report, we presented the course and onset of NMS and catatonia in our patient, which was most likely due to the use of 2 antipsychotic agents." Che J, et al. Catatonia after neuroleptic malignant syndrome successfully treated with electroconvulsive therapy. Primary Care Companion to the Journal of Clinical Psychiatry 21: No. 4, 2019. Available from: URL: http://doi.org/10.4088/ 803436855 PCC.18l02376 - USA

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