Neuroleptic Malignant Syndrome Due to Risperidone Misdiagnosed As

Pediatric Reports 2011; volume 3:e19

Neuroleptic malignant of adrenoceptors may further increase pre- frontal cortical activity and could enhance Correspondence: Ali Ertug Arslankoylu, Mersin syndrome due to risperidone antipsychotic efficacy by modulations of University Faculty of Medicine, Department of misdiagnosed as status mesolimbic DA activity. Unlike other atypical Pediatrics, Pediatric Intensive Care Unit. 33079, epilepticus agents, risperidone does not differ from con- Mersin, Turkey. ventional agents in its dissociation contrast for Tel. +90.324.3374300.1161 - Fax: +90.324 3374305. E-mail: [email protected] Ali Ertug Arslankoylu, Meryem Ozlem D2 receptor; this feature perhaps accounts for the risk of EPS (extrapyramidal side effects) at Kutuk, Cetin Okuyaz, Fevziye Toros Key words: neuroleptic malignant syndrome, high doses.4 However in large multicentre risperidone, status epilepticus. Mersin University Faculty of Medicine, studies it was shown that risperidone had sim- Department of Pediatrics, Pediatric ilar side effects like other typical neuroleptic Contributions: AEA, manuscript preparation Intensive Care Unit, Mersin, Turkey agents.5 As far as we know the number of cases supervision; MOK, data conception and design; due to risperidone treatment in the literature CO, FT, manuscript revision; AEA,MOK, CO, FT, is limited and most of the reported cases are final manuscript approval. adults. In most of these cases risperidone Abstract induces NMS after two weeks of treatment.6 Received for publication: 27 May 2011. Here we report a child with NMS due to Accepted for publication: 21 June 2011. Neuroleptic malignant syndrome (NMS) is a risperidone treatment who was misdiagnosed This work is licensed under a Creative Commons rare but potentially fatal disease characterized as status epilepticus. The patient reported Attribution NonCommercial 3.0 License (CC BY- by fever, muscle rigidity, delirium and autonom- here met DSM-IV criteria for NMS.1 NC 3.0). ic instability. Here we report a child, with NMS due to the risperidone misdiagnosed as status ©Copyright A.E. Arslankoylu et al., 2011 epilepticus. Nine year old boy, who had been Licensee PAGEPress, Italy under high dose risperidone treatment for 8 Case Report Pediatric Reports 2011; 3:e19 doi:10.4081/pr.2011.e19 weeks, admitted to the emergency room because of the contractions (evaluated as status Nine years old boy was admitted to the only epilepticus) persisting for 7 hours. Since there emergency department because of the convul- was neuroleptic treatment in the past medical sions persisting for seven hours. He had atten- EEG were unremarkable. history and, unconsciousness, muscular rigidi- tion deficit hyperactivity disorder and he had Although the tremors accompany muscular ty, diaphoresis, hypertermi and, hypotension in been under risperidone (2¥2 mg/day)use treat- rigidity were mimicking convulsions and the physical examination, leucocytosis and elevated ment orally for 8 weeks because of moderate patient was admitted with staus epilepticus creatininphosphokinase levels in laboratory mental retardation and psychological disorder. diagnosis, the patient was not diagnosed as tests, the patient was evaluated as NMS and dis- Risperidone dose was four times more than status epilepticus because there were neu- charged without any complications. We reported usually recommended pediatric dosage. roleptic treatment in his medical history, mus- this case to point out that; NMS may be misdi- Additionally the patient had been suffering cular rigidity, diaphoresis, hypertermi and agnosed as status epilepticus in children when vomiting, tremor and fever for two weeks. hypotension in physical examination, leucocy- EEG monitoring is unavailable. When a child Physical examination in the emergency tosis and elevated CPK levels in laboratory admitted to the emergency room because of room revealed a body temperature of 39°C, a tests. By the help of the sign and symptoms suspicious convulsion neuroleptic drug use respiratory rate of 10 breaths/min, and, a pulse above, the patient was diagnosed as NMS by must surely be asked. rate of 158 beats/min. Blood pressure was too pediatric critical care intensivist, pediatric low that it couldn’t be measured initially. The neurologist and pediatric psychiatrist. NMS patient’s general appearance was lethargic. diagnosis was confirmed with EEG and risperi- There was muscular rigidity, tremor and, done treatment was ceased. Introduction diaphoresis. He was dehydrated. Heart sounds In the emergency department the patient were rhythmic and tachycardic. His respiration was entubated because of respiratory failure. Neuroleptic malignant syndrome (NMS) is a was weak and respiratory sounds were normal. Then he was admitted to the pediatric inten- rare but potentially fatal disease Non-commercialcharacterized Bilateral pupil reflexes were positive. Deep sive care unit and mechanically ventilated. by fever, muscular rigidity, delirium and auto- tendon reflexes were brisk and bilateral Intravenous diazepam infusion (0.3 mg/kg nomic instability.1 Yearly prevalence of the dis- Babinski reflexes were positive. There were no hour) and carbidopa/levodopa were given for ease in patients under neuroleptic treatment meningeal irritation signs. NMS treatment. In the first day of the admis- ranges between 0.02% and 2.4%. Mortality rate Initial laboratory analysis revealed a white sion to the intensive care unit the patient had of the patients without specific treatment is blood cell count of 21580 cells/mm3, with 2% hyperthermia resistant to the antipyretic treat- approximately 21%.2,3 Mortality rate may be band neutrophils, 62% neutrophils, 30% lym- ment and his blood pressure was unstable. higher in patiens with misdiagnosis like our phocytes, 6% monocytes. Serum electrolytes Central venous catheter was placed and hemo- patient. The classic presentation of this syn- were in normal ranges included a sodium level dynamic parameters of the patient were regu- drome has been most commonly associated of 136 mEq/L; potassium, 5.4 mEq/L; chloride lated in normal ranges. In the second day of with the typical neuroleptic drugs such as 105 mEq/L and, calcium 8.2 mEq/L. The blood the admission to the intensive care unit the haloperidol.2 glucose was 316 mg/dl. Initial venous blood patient was extubated. All the clinical and lab- Risperidone is a new atypical neuroleptic gases showed a pH of 7.04; carbon dioxide ten- oratory signs and symptoms of the patient agent. 5-HT2A antagonism partially protects sion 95 mmHg; bicarbonate 26 mEq/L and, base improved except elevated creatinin phosphoki- against D2 antagonist-induced-neurologic side excess, -5.8 mmol/L. The serum creatinine nase levels which turned back to normal values effects and, may improve negative symptoms phosphokinase (CPK) level was 1658 U/L. on the fifth day of the admission. Then he was and cognitive functioning via modulation of Blood, urine and stool cultures were negative. discharged from the hospital without compli- mesocortical DA activity. In addition, blockade Urinalysis, chest radiograph, cranial CT and cations.

[Pediatric Reports 2011; 3:e19] [page 81] Case Report

with dopamine. 2. Leibold J, Patel V, Hasan RA. Neuroleptic Discussion Previously it was thought that NMS was only malignant syndrome associated with associated with the use of classical neurolep- ziprasidone in an adolescent. Clin Ther Here we report a patient with NMS who was tics. However there are some NMS cases due 2004;26:1105-8. misdiagnosed as status epilepticus before to atypical neuroleptics in the literature.7 As 3. Steingard R, Khan A, Gonzales A, Herzog admission to our hospital. Our patient was far as we know in the literature only two NMS D. Neuroleptic malignant syndrome: diagnosed as NMS due to presence of men- cases due to risperidone treatment were review of experience with children and tioned criteria of NMS.1 Mortality rate of NMS reported in children.8,9 We think that atypical adolescents. J Child Adolesc Psychophar - in the patients without specific treatment is neuroleptics will be extensively used in chil- macol 1992;2:183-98. approximately 21%.2,3 Mortality rate may be dren in the future and the clinicians especial- 4. Gertz HJ, Schmidt LG. Low melatonin con- higher in patiens with misdiagnosis. NMS ly the pediatricians must be familiar to NMS tent of substantia nigra in a case of neu- signs and symptoms may be difficult to differ- and its differential diagnosis. roleptic malignant syndrome. Pharmaco- entiate from status epilepticus by inexperi- We report this case in order to underline psychiatry 1991;24:93-5. enced physicians when EEG monitoring is that neuroleptic malignant syndrome may be 5. Ballard C, Grace J, Mckeith J, Holmes C. unavailable. As mentioned before, our patient misdiagnosed as status epilepticus in children Neuroleptic sensitivity in dementia with was diagnosed as status epilepticus before he when EEG monitoring is unavailable. When a Lewy bodies and Alzheimer’s disease. was admitted to our hospital and he had been child is admitted to the emergency department Lancet 1998;351:1032. tried to be treated as status epilepticus at the because of unconsciouesness muscular rigidi- 6. Caroff SN, Mann SC. Neuroleptic malig- beginning. ty, diaphoresis, hypertermi and hypotension; nant syndrome. Med Clin North Am 1993; The clinical signs and symptoms of our neuroleptic drug use must surely be asked. 77:185-202. patient emerged in the second week of the Furthermore this is the third neuroleptic 7. Srivastava A, Borkar HA, Chandak S. risperidone treatment. As it was pointed out malignant syndrome case due to risperidone Olanzapine-induced neuroleptic malig- before NMS may occur in anytime during neu- treatment in children. Early diagnosis and nant syndrome in a patient with paranoid roleptic treatment.6 proper treatment of NMS may decrease the schizophrenia. Psychiatry Clin Neurosci First step of the NMS treatment is to cease mortality rates significantly. 2009;63:119-21. antipsychotic drugs. After we diagnosed NMS 8. Chunghonly DS, Kim BN, Cho SC. Neuroleptic we discontinued the risperidone treatment. malignant syndrome due to three atypical Cooler blankets and antipyretics for hyperther- antipsychotics in a child. J Psychopharma - mia and supportive treatment including fluid References col 2005;19:422-5. electrolyte therapy must be supplied. In med- use9. Vurucu S, Congologlu A, Altun D, et al. ical treatment in order to reduce muscular 1. American Psychiatric Association. Diagno - Neuroleptic malignant syndrome due to rigidity dopamine agonists are used. Similarly stic and statistical manual of mental disor- risperidone treatment in a child with we used dopamine agonists for our patient. ders, Revised fourth edition. Washington, Joubert syndrome J Natl Med Assoc 2009; Additionally dantrolene may be used alone or DC: American Psychiatric Press; 2000. 101:273-5.