Antipsychotics
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Neuroleptic malignant syndrome: case report An adult man in his early 20s [exact age not stated] developed neuroleptic malignant syndrome (NMS) during antipsychotic treatment with ziprasidone, aripiprazole, clonazepam and zuclopenthixol [not all routes stated; dosages and duration of treatments to reaction onset not stated]. The man, who had schizophrenia spectrum, substance use disorder, paranoid delusions and auditory hallucinations (since his early teens), had started taking oral stimulants in form of crystal methamphetamine monthly in his late teens. He was admitted in a forensic psychiatry inpatient ward due to erratic and aggressive behaviour in prison, threatening family members as well as inmates and punching walls. During admission, he was receiving oral ziprasidone, which was started several weeks prior to his imprisonment. His affect became more restricted after 2 weeks, and he ceased the medications for 5 days because of subjective of lack of effect. Psychiatry staff convinced him to restart ziprasidone at a reduced dose. However, his behaviour worsened progressively in terms of angry spells and again he refused to take medications. Therefore, his treatment was switched to aripiprazole and a low-dose oral clonazepam. Shortly after starting aripiprazole, his irritability started to increase again. He reported that the irritability was related to the new environment and the aripiprazole helped him to stay calm. He insisted to increase the dosage, after which the irritability and anger spells reduced. Two weeks later, he was found to be wearing a thick pullover on the daily round despite warm temperature and sweating. He was not hypervigilant or agitated. He refused to talk but communicated with head nodding or shaking. Due to the risk of over-sedation, the clonazepam dose was reduced. Over the next 2 days, he developed unusual behaviour and bizarre persecutory delusions. He started to constantly remove most of his clothing, was unable to follow rules and pacing the hallway. Because of non-compliance, increasing violent behaviour and paranoia, he was started on IM injection of zuclopenthixol [Clopixol-Acuphase]. The following day, he was more compliant and calmer, but paranoia increased further with a new onset of vague suicidal thoughts. His movements slowed and thinking was disordered. He was suspected to have developed catatonic-like features. The following night, he had some posture abnormalities in the form of ambitendency and mild posturing. His vitals were normal except mild tachycardia. Physical examination revealed mild rigidity on arm extension. Blood testing revealed elevated creatinine kinase levels, indicative of rhabdomyolysis. Thus, based on the findings and his clinical picture, he was diagnosed with life-threatening NMS. The man was immediately transferred to ICU, and was treated with dantrolene and bromocriptine. On the same day, he also developed acute kidney injury and required dialysis. Following several weeks in the ICU, his kidney function recovered and he was shifted to the for
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