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

Abstract

Background Neuroleptic malignant syndrome (NMS) is a rare and life‐threatening reaction. The incidence rate of NMS has dropped because of the higher use of atypical antipsychotics, compared with the typical ones. The mortality rate in patients taking injectable antipsychotics has been also by 38%. Aim Here, a case developing the NMS symptoms following Flupentixol (FPX) use was reported. Case presentation The patient was a 46‐year‐old man with the history of schizoaffective disorder (SAD) and recently on six‐weekly doses of long‐acting (LA) typical antipsychotic drugs. He was referred with a fever, sweating, a food intolerance, mutism, and disorientation in 2019. He was presented with generalized rigidity, negativism, and neck stiffness. The patient's initial creatine phosphokinase (CPK) level was 1476 IU/L, which gradually elevated to 3997 IU/L on Day 26. NMS was further diagnosed, in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5) criteria, and the score 9+ in the Naranjo Algorithm as the adverse drug reaction probability scale. Afterward, the patient was treated with bromocriptine at a dose of 5 mg 3 times a day, which progressively reached a maximum of 50 mg. He experienced sepsis and resistant respiratory infection several times. The case was finally discharged after 66 days of hospitalization, with a high level of consciousness, but limited verbal communication, in a fever‐free condition with the oral administration of bromocriptine and lorazepam. Conclusion In conclusion, there were suggestions for the management challenges of NMS in patients receiving LA injectable antipsychotic agents.

The diagnostic dilemma in a patient with neuroleptic malignant syndrome during the COVID‐19 pandemic: A significant increase in acute phase reactants

“…Neuroleptic malignant syndrome (NMS), as an acute, rare, life‐threatening, and idiosyncratic condition, is generally triggered in reaction to dopamine receptor antagonist agents, such as typical or conventional antipsychotics, atypical antipsychotic agents, and metoclopramide, levodopa, and amantadine withdrawal 1 . This complication is characterized by very high fever, muscle rigidity, tremors, autonomic nervous system (ANS) instability, hyperhidrosis, dysphagia, altered level of consciousness (ALOC), leukocytosis, and elevated creatine phosphokinase (CPK) 2 . The underlying pathophysiological mechanisms of NMS are still vague, 3 and those caused by antipsychotics are often associated with its impact on dopamine in the mesocortical‐nigrostriatal pathways and the hypothalamic nuclei 3 .…”

“…The underlying pathophysiological mechanisms of NMS are still vague, 3 and those caused by antipsychotics are often associated with its impact on dopamine in the mesocortical‐nigrostriatal pathways and the hypothalamic nuclei 3 . As shown by previous studies, the incidence rate of NMS has had a downward trend over the recent years, due to the growth in the prescription of atypical antipsychotic drugs compared to the typical ones, reaching 0.01%–0.02% in cases undergoing treatment, and even 0.07%–3.22% in some reports 1–4 . On the contrary, malnutrition, dehydration, iron deficiency, exposure to extreme heat, hyponatremia, and thyrotoxicosis have been characterized to increase the risk of this condition 5 .…”

“…1 This complication is characterized by very high fever, muscle rigidity, tremors, autonomic nervous system (ANS) instability, hyperhidrosis, dysphagia, altered level of consciousness (ALOC), leukocytosis, and elevated creatine phosphokinase (CPK). 2 The underlying pathophysiological mechanisms of NMS are still vague, 3 and those caused by antipsychotics are often associated with its impact on dopamine in the mesocortical‐nigrostriatal pathways and the hypothalamic nuclei. 3 As shown by previous studies, the incidence rate of NMS has had a downward trend over the recent years, due to the growth in the prescription of atypical antipsychotic drugs compared to the typical ones, reaching 0.01%–0.02% in cases undergoing treatment, and even 0.07%–3.22% in some reports.…”

“… 3 As shown by previous studies, the incidence rate of NMS has had a downward trend over the recent years, due to the growth in the prescription of atypical antipsychotic drugs compared to the typical ones, reaching 0.01%–0.02% in cases undergoing treatment, and even 0.07%–3.22% in some reports. 1 , 2 , 3 , 4 On the contrary, malnutrition, dehydration, iron deficiency, exposure to extreme heat, hyponatremia, and thyrotoxicosis have been characterized to increase the risk of this condition. 5 The mortality rate caused by NMS had been already estimated to be over 30%.…”