Ileus as a Sign of Neuroleptic Malignant Syndrome: A Case Report and Review of the Literature

Abstract

Introduction: Neuroleptic malignant syndrome (NMS) is a rare and unpredictable adverse reaction associated with the use of firstgeneration and second-generation antipsychotics. Atypical antipsychotics may create atypical forms of NMS due to their different pharmacological characteristics. Decreased dopaminergic tone in the brain is coincided with a dysregulation of autonomic nervous system in this syndrome. This study reports on a case, in which current views occurred during the course of the disease is among rare symptoms. This paper reports on an NMS case, in which current views and symptoms that occurred during the course of the disease were rare symptoms that are not usually found in NMS. Case Presentation: The patient was a 43-year-old male with schizoaffective disorder under treatment with clozapine and risperidone. He had lead pipe muscle rigidity, stupor, fever and autonomic dysfunction, increased levels of creatinine phosphokinase, leukocytosis, and microglobulina. Levenson's criteria is widely accepted for diagnosis of NMS. Six days after admission to the psychosomatic ward, the patient had ileus. Due to lack of response to neomycin and GI rest and embedding NG tube, the patient underwent therapeutic sigmoidoscopy and colonoscopy for decompression. Conclusions: Diagnosis of NMS is largely based on clinical history and the presence of specific clinical symptoms. Antipsychotics polypharmacy increases the NMS risk. Mechanisms underlying the development of ileus in the patient are speculative and multifactorial. Paralytic ileus can be one of the autonomic dysfunctions in NMS. Furthermore, NMS is categorized in differential diagnosis of acute abdomen caused by the pseudo-obstruction. All physicians should be aware of this possibility when faced with patients under treatment with neuroleptics.

Metoclopramide-Induced Neuroleptic Malignant Syndrome: A Review Study

“…This complication was initially described by Delay et al in 1968 due to haloperidol use (1,2). The incidence rate of this side effect in patients taking psychotropic medications has been reported as 0.02% -1.4%, with a mortality rate of 10% -20% (3)(4)(5). The main symptoms of NMS resemble malignant hyperthermia, including increased body temperature (fever), imbalance of autonomic nervous system, and loss of consciousness.…”

“…The neuroleptic malignant syndrome has been introduced as a rare but lethal and idiosyncratic reaction to neuroleptics/antipsychotics (5,9). In uncommon cases, generally associated with low-potency antipsychotics, muscle rigidity may be milder or may not be observed at all.…”

“…The exact cause of NMS development is unknown. However, NMS can be assumed as the result of maladjustments in several neuromuscular and intrinsic nervous systems occurring at the last stage of the hypermetabolic syndrome (5). Hypermetabolic muscle state is also one of the two main theories raised about the pathogenesis of this syndrome (similar to what appears in malignant hyperthermia).…”

The management challenges of a case with Flupentixol‐induced neuroleptic malignant syndrome

“…6 The developmental mechanism of NMS caused by antipsychotic drug use is often associated with the effects on dopaminegenerated occlusion in the mesocortical-nigrostriatal pathways and the hypothalamic nuclei. 6 The incidence rate of this side effect in patients taking antipsychotics has been so far reported at 0.4-0.02%, with the mortality rate of 10-30%, 7 which has been 38% for the injectable ones. 8 As confirmed in numerous studies, the incidence rate of NMS has dropped in recent years because of the higher use of atypical antipsychotics, compared with the typical ones.…”