Neuroleptic malignant syndrome and psychotic illness

Article Abstract:

Neuroleptic malignant syndrome (NMS) is a rare but often fatal condition associated with the administration of antipsychotic (neuroleptic) medication. Symptoms include rigidity, tremor, high fever, and coma. The case report of a 20-year-old single woman who was successfully treated for NMS is presented, in which a relationship between the alleviation of NMS symptoms and a return of psychotic symptoms was noted. The patient was admitted to the hospital with a diagnosis of catatonic schizophrenia and treated with neuroleptics. She became confused and restless, developed a fever and demonstrated abnormal movements. A provisional diagnosis of NMS was made. Neuroleptics were discontinued and she was placed on bromocriptine to treat the NMS. As symptoms of NMS subsided, psychotic symptoms re-emerged. Electroconvulsive therapy (ECT) alleviated her symptoms for a week, but she then became assaultive and delusional. More ECT sessions relieved her symptoms. It is generally believed that NMS occurs in association with the neuroleptic blockade of dopamine (a brain messenger that has been associated with some forms of psychosis and movement disorders) and that florid psychotic symptoms are caused by a state of excessive dopamine. Therefore, in theory, psychotic symptoms should not occur during an episode of NMS. Bromocriptine works by enhancing activity caused by dopamine, but the doses used to treat NMS are very low and have not been known to cause psychosis in other patients. Since this patient only received low doses of bromocriptine for two weeks, the return and progressive worsening of her psychosis remains unexplained. It is suggested that her recovery from NMS may have been related to the re-establishment of an earlier, dysfunctional neurochemical state. (Consumer Summary produced by Reliance Medical Information, Inc.)

Physiological aspects, Schizophrenia

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The treatment of neuroleptic malignant syndrome: are dantrolene and bromocriptine useful adjuncts to supportive care?

Article Abstract:

Neuroleptic malignant syndrome (NMS) is characterized by fever, delirium, sweating, and tremors. It is an adverse reaction to treatment with neuroleptic drugs and can be life-threatening. Treatment of NMS includes discontinuing the neuroleptic medication, providing intravenous fluid replacement, and controlling fever. There have been reports that the drugs dantrolene and bromocriptine may be useful in treating NMS. In the present study, 20 patients experiencing a first episode of NMS were identified. In all cases, treatment with neuroleptic medication was discontinued, and intravenous fluids were administered along with treatment of fever. In addition, two patients received dantrolene at 240 to 600 milligrams per day, two received bromocriptine at 7.5 to 30 mg/day, and four patients received both drugs. The patients were divided into two groups based upon whether they received dantrolene/bromocriptine or just supportive care; sociodemographic and medical data from all subjects were compared. No significant differences in the subjects before the onset of NMS were found. The treatment course for both groups appeared to be essentially the same. There was an initial, sometimes sudden, improvement in symptoms within the first four days of treatment, and the illness had an average duration of 6.8 days for those in supportive care only and 9.9 days for those receiving the drugs. Those who received only supportive care also had fewer symptoms during the course of illness than those receiving dantrolene/bromocriptine. However, it may be that this variation in symptoms was simply due to the natural course of NMS, and not to the drugs themselves. No evidence supporting the use of either drug in treating NMS was found. (Consumer Summary produced by Reliance Medical Information, Inc.)

Drug therapy

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The (frequently) neuroleptic (potentially) malignant syndrome

Article Abstract:

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal condition associated with the administration of some neuroleptic (antipsychotic) medications. NMS symptoms include Parkinsonian-type rigidity and tremors, very high fevers, and coma. Studies assessing the incidence of NMS have yielded inconsistent and contradictory data. Standard treatment has been the withdrawal of the causative agent, plus supportive measures. However, evidence from case reports indicates that treatment with oral bromocriptine, sometimes given with dantrolene, is associated with relatively rapid improvement and higher survival rates. An analysis that combined data from various studies (called a meta analysis), yielding a total of 536 NMS patients, demonstrated that the majority of cases occurred in men aged 20 to 40 years. Relatively low peak temperature during NMS was strongly associated with survival. Of the 42 patients treated solely with bromocriptine, five died (12 percent). Seven of the 44 patients treated with only dantrolene died (16 percent), while 29 of the 109 patients treated only with supportive measures died (27 percent). Of the 22 patients treated with bromocriptine plus dantrolene, three died (14 percent). Several patients were treated with amantadine and L-dopa (anti-parkinsonism drugs), with an almost 100 percent rate of success. However, this success was difficult to evaluate because the patients may have also been taking bromocriptine and dantrolene. There were no clear relationships found between a patient's psychiatric diagnosis and NMS survival. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patient outcomes, Mortality, Antipsychotic drugs, Antipsychotic agents

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