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Neuroleptic Malignant Syndrome: a Case Report with Post-Mortem Brain and Muscle Pathology

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Neuroleptic Malignant Syndrome: a Case Report with Post-Mortem Brain and Muscle Pathology J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.8.1006 on 1 August 1989. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry 1989;52:1006-1009 Short report Neuroleptic malignant syndrome: a case report with post-mortem brain and muscle pathology ERICA M JONES,* ALLAN DAWSONt From the University ofBristol,* and Frenchay Hospital,t Bristol SUMMARY The neuroleptic malignant syndrome is a rare but dangerous complication of treatment with neuroleptics. The aetiology and pathophysiology ofthe syndrome are reviewed, and a fatal case is presented where both brain and muscle pathology are described. Striking myopathic changes in this case, accompanied by only minimal and non-specific brain abnormalities, support a peripheral rather than central mechanism for the hyperthermia. The term neuroleptic malignant syndrome was oxidase inhibitors (MAQIs) in overdose have also introduced into English medical literature by Delay been implicated.6 Some authors have suggested that and Deniker' in 1968, and since an article by Caroff 2 in concurrent treatment with lithium increases vul- Protected by copyright. 1980 interest in the syndrome has flourished.>' It is a nerability to the syndrome.39 rare8'0 but potentially fatal hypersensitivity response in certain patients exposed to neuroleptic medication. Case report The core features are a diffuse muscular rigidity (often with extrapyramidal or catatonic signs), hyperthemia, A 70 year old widow suffering chronic depression had been autonomic instability, and altered consciousness; an inpatient on a longstay psychiatric ward for 2 years when typically these develop days or weeks after starting she became suddenly distressed and unwell, with dyspnoea, tachycardia of 150, diffuse muscular rigidity, and a pyrexia of neuroleptic treatment and progress over 24-72 hours. 39-4°C. Within 1 hour she became cyanosed, hypotensive (BP Associated findings include a leucocytosis, elevated 80/30 mmHg), and deeply comatose, with generalised serum potassium, and elevated serum creatine phos- rigidity and marked hyperreflexia. Her treatment at this time phokinase (CPK), the latter reflecting skeletal muscle included a MAOI (isocarboxazid 10 mg od) and a neurolep- necrosis. Mortality is about 20%2 and is particularly tic (chlorpromazine 25 mg tds). associated with long acting (depot) neuroleptics, a After initial resuscitative measures, the patient was trans- diagnosis ofschizophrenia, and organic brain disease.6 ferred to a general hospital, where she had a grand mal fit. The syndrome has been reported to occur in a wide Investigations revealed a mild neutrophil leucocytosis, elevated serum potassium (6 mmol/l) and CPK (3,300 IU/1) range ofpsychiatric disorders apart from schizophren- http://jnnp.bmj.com/ 8 9 12 16 and a sinus tachycardia on ECG. Chest radiograph, blood ia,3 and indeed has occurred in well patients as a glucose, lumbar puncture, serial blood cultures and CT ofthe complication of pre-operative medication." Some head were normal. cases have occurred in the absence of a history of Combining the clinical picture and the results of the initial neuroleptic treatment, for example due to dopamine investigations, a diagnosis of neuroleptic malignant syn- depleting drugs such as tetrabenazine and alpha- drome was made. Treatment comprised discontinuation of methyltyrosine in Huntington's chorea,'3 and all psychotropic drugs, cooling, intravenous fluids and withdrawal of dopamine agonists such as levodopa anticonvulsants. Within 24 hours the patient's clinical state and amantadine in Parkinson's disease.3121415 Com- improved considerably; her muscle rigidity and pyrexia on September 25, 2021 by guest. binations of tricyclic antidepressants and monoamine resolved, and she regained full consciousness. However, as a result of widespread rhabdomyolysis she developed acute renal failure from which she died some days later. It is of interest that throughout the previous two years of Address for reprint requests: Dr E Jones, Department of Mental inpatient care, the patient had developed an unexplained Health, Bristol University, 41 St Michael's Hill, Bristol BS2 8DZ, UK toxic confusional state on six occasions. During this period Received 3 June 1988 and in revised form 9 January 1989. Accepted 22 she had received neuroleptics intermittently. These episodes March 1989 were characterised by acute confusion with restlessness and 1006 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.8.1006 on 1 August 1989. Downloaded from Neuroleptic malignant syndrome: a case report with post-mortem brain and muscle pathology 1007 3r- o e F K I~~~~~~~~~~~~~~~~~~~~~~~~I .....*..;.... 7 ii - A~~~~~ :r::: a ,vs Bs. '"4:ag ^:: <vb 44 : S vI. sS-~~~~~~~~~~~~~... ..... *E;_ v \ }; n X v <~~~~~~~ .. * : tX / e 4 % 7 .. !t 4. .;,t;s:z;sA" # / tS S ..... ,, >! R w/aia - .2;.% ......... ? ;s f i . ¾-iw: .I e Protected by copyright. SaX. ,a Fig Section ofpsoas muscle showing myopathicfeatures. bizarre posturing, brief loss of consciousness (on four and perivascular haemorrhages, but no areas of necrosis. occasions), and Parkinsonian rigidity (with trismus on one Further similar changes were present in the hindbrain. occasion); some were accompanied by a mild pyrexia of Microscopic examination ofthe kidney showed acute tubular 37-5°C, hypertension, and urinary instability (both incontin- necrosis. ence and retention). Repeated investigations including haematology, biochemistry, infection screen, chest radiogra- Discussion phy, ECG, and CT of the head were normal. EEG showed generalised excess fast activity on two occasions. Serum CPK The clinical features and results of in had not been estimated. investigations this patient's terminal illness are typical of the http://jnnp.bmj.com/ Her and sex are Post-mortem examination neuroleptic malignant syndrome.2 age unusual, as the syndrome appears to have a predelic- Post-mortem examination, performed 6 hours after death, tion for young males.2 The neuroleptic malignant showed scattered petechial subarachnoid haemorrhages over syndrome can reoccur in the same patient, sometimes the brain, which was otherwise macroscopically normal, and pursuing a milder chronic course before relapsing into further petechiae over the surfaces of the kidneys. Sections of an acute fulminant picture.8"'7" It therefore seems muscle taken from psoas showed an increase in muscle fibre probable that this patient's earlier confusional states size, which was myopathic in appearance, and an acute represented a prodromal phase of the actual syn- on September 25, 2021 by guest. disseminated segmental necrosis with regeneration. drome. Occasional fibres showed distinct multiple vacuolation (fig). There has been considerable interest in the patho- There was no fibrosis or increase in internal nucleation. physiology of the syn- Cerebral sections showed a number of foci of acute neuroleptic malignant tiny 4 ischaemic change in the lateral corpus callosum, internal drome,3 21-23 and in particular in the role of dopamine capsule and globus pallidus, together with some recent imbalance in the central nervous system. It has been extravasation of blood in the subarachnoid space. The postulated that the trigger is a sudden decrease of hypothalamus showed a number of similar tiny parenchymal activity at central dopamine receptors, produced J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.8.1006 on 1 August 1989. Downloaded from 1008 Jones, Dawson either by dopamine depleting or blocking drugs, or References abrupt withdrawal of dopamine agonists. Although it has long been established that pheno- I Delay J, Deniker P. Drug-induced extrapyramidal syndromes. In: Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology. thiazines may reduce body temperature (indeed hypo- Diseases of the Basal Ganglia. Amsterdam: North Holland thermia is a recognised complication of their use), the Publishing Co., 1968;6:248-66. sites and mechanisms oftheir thermoregulating action 2 CaroffSN. The neuroleptic malignant syndrome. J Clin Psychiatry in man are largely unknown. Controversy exists over 1980;41:79-83. 3 Levenson JL. Neuroleptic malignant syndrome. Am J Psychiatry whether the hyperpyrexia in the neuroleptic malignant 1985;142: 1137-45. syndrome is a central effect of neuroleptics or a 4 Abbot RJ, Loizou LA. Neurolpetic malignant syndrome. Br J peripheral effect within skeletal muscle.24 Attention Psychiatry 1986;148:47-51. to the similarity between the neurolep- 5 Shalev A, Munitz H. The neuroleptic malignant syndrome: agent has been drawn host interaction. Acta Psychiatr Scand 1986;73:33747. tic malignant syndrome and malignant hyperpyrex- 6 Kellam AMP. The neuroleptic malignant syndrome, so-called, a ia.22'2' The latter is an inherited liability to develop an survey of the world literature. Br J Psychiatry 1987;150:752-9. abnormal muscle reaction in response to anaesthetic 7 Murray JB. Neuroleptic malignant syndrome. J Gen Psychol agents. However, in vitro experiments on samples of 1987;114:39-46. 8 Addonizio G, Susman VL, Roth SD. Symptoms of neuroleptic muscle from patients with both conditions have malignant syndrome in 82 consecutive inpatients. Am J Psy- revealed distinct differences.2428 Further, whilst dan- chiatry 1986;143:1587-90. trolene has been employed successfully in both condi- 9 Pope HG, Keck PE, McElroy SL. Frequency and presentation of tions, its benefits appear to be only partial and less neuroleptic malignant syndrome in a large psychiatric hospital. Am J Psychiatry
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