QUICK OVERVIEW ABOUT PATIENT:
Patient comes in with fever 101.3, some mild confusion, muscle rigidity, recently started risperidone 10 days ago. BP 200/110. Tested negative for influenza. CXR & UA normal. CT head normal. No photophobia or neck stiffness. Negative brudzinski sign. No recent vaccinations. No falls or head trauma. No rashes, recent travel, or sick contact.
WHAT IS YOUR GUESS? NEED MORE INFO BEFORE YOU DECIDE, SEE INFO BELOW:
MORE DETAILED INFO ABOUT PATIENT:
A patient comes in complaining of a fever of 101.3. The fever started today. They also complain of a tremor and “stiff” muscles. They deny any SOA, chest pain, nasal drainage, coughing, wheezing, pharyngitis, or sinus pressure. They have not had any recent sick contact. They deny any photophobia, stiff neck, diarrhea, abdomen pain, or dysuria. They have not had any falls or trauma.
PHYSICAL EXAM: Their blood pressure is 200/110, HR 104, Temp 101.3, 02 93%, R 23. On exam, you note that their upper and lower extremities seem very rigid. Auscultation of lungs clear. HRR. They are mostly alert and oriented, but you do notice some mild confusion when they answer questions about the details of their day. Negative brudzinski sign. Neck full ROM. Their gait is shuffled and unstable. Integument: no rashes, wounds, ulcers.
FAMILY HX: Depression, Schizophrenia, Bipolar
VACCINATIONS: Did not get Influenza vaccine or any other vaccine recently
LABS & OTHER TESTS: Serum CK level 534, AST, ALT, and WBC are mildly elevated. Their potassium is at 5.8. Their creatinine is also elevated at 1.9. Other labs: B12, TSH, & ammonia levels are all normal. UA does not show a urine infection. Influenza A & B are negative.
IMAGING & OTHER TESTS: CXR and CT scan of head does not reveal any acute finds. Carotid doppler no stenosis revealed
Patient recently started a new medication- risperidone 10 days ago. They have never been on this medication or any medication like it before.
What is the most likely diagnosis?
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ANSWER
Neuroleptic Malignant Syndrome
OTHER ANSWERS: This patient may also be going into rhabdomyolysis and ARF too, which are complications of NMS. If you guessed these things too-awesome!
WHAT: Considered a medical emergency. It is a reaction to antipsychotic medication
MEDS THAT CAN CAUSE: New & older antipsychotics such as aripiprazole, olanzapine, clozapine, quetiapine, risperidone, ziprasidone, chlorpromazine, haloperidol, loxapine. Also some antiemetics can cause too: metoclopramide, promethazine, prochlorperazine
LABS: Although there are no diagnostic labs specific to NMS some labs may be abnormal due to other complications of NMS (including rhabdo and ARF). So may see labs like: elevated ck, potassium, high creatinine). On CBC may see an elevated WBC. It is important to rule out other potential differential Dx such as sepsis.
DX TESTS: CT head usually normal, blood cx normal, CXR normal
S/S: Fever-hyperthermia, hypertension, muscle rigidity, altered mental status, incontinence, diaphoretic, tremor, shuffled gait, tachycardia, tachypnea, dysphagia
RISK: Starting anti-psychotic medication. Usually happens within 10 days (90% of cases 1. emedicine.medscape.com)
TREATMENT: Stop antipsychotics or other medication that is cause (see above for meds that cause. Dopamine antagonist must be stopped too). Blood pressure control, hydration especially to prevent renal failure, cooling. Antipyretics such as acetaminophen & ibuprofen do not seem to help much in NMS. Dysphagia-may need an NG tube for medication administration. Lorazepam is used for any agitation and also for muscle relaxation as well. Tx overall is usually supportive (2-epocrates).
REFERENCE:
- Neuroleptic Malignant Syndrome-Emedicine.medscape.com
- Epocrates: Neuroleptic Malignant Syndrome
. I highly recommend signing up for Epocrates. There is a free (drugs) and a paid version- runs anywhere from 150-180 per year-but so worth it! I have been using it for years and years and couldn’t go without it! I use it more than any other medical app.
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