Diagnostic uncertainty in a case of neuroleptic malignant syndrome

ABSTRACTNeuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that has been associated with antipsychotic use. Most diagnostic criteria include fever and muscle rigidity, although NMS may present without either. Diagnostic uncertainty in such cases may result in delays in diagnosis and management, leading to adverse consequences for these patients. The differential diagnosis of NMS is broad and includes a number of neurological, medical and psychiatric conditions as well as substance and medication-induced disorders. A case is described that illustrates an atypical presentation of NMS and demonstrates some of the challenges in its diagnosis. Limitations of current NMS criteria are also examined, and suggestions for future criteria are presented.

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Hyperthermia and neuroleptic malignant syndrome-Case report

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.1626 ◽

2017 ◽

Vol 41 (S1) ◽

pp. s829-s830

Author(s):

K. Puljić ◽

M. Herceg ◽

V. Jukić

Keyword(s):

Malignant Hyperthermia ◽

Neuroleptic Malignant Syndrome ◽

Altered Mental Status ◽

Muscle Rigidity ◽

Idiosyncratic Reaction ◽

Malignant Neuroleptic Syndrome ◽

Neuroleptic Syndrome ◽

Threatening Condition ◽

Life Threatening ◽

Competing Interest

Neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to neuroleptic medications that is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction. NMS often occurs shortly after the initiation of neuroleptic treatment, or after dose increases. Malignant hyperthermia (MH) or malignant hyperpyrexia is a rare life-threatening condition that is usually triggered by exposure to certain drugs. The 46-years-old female patient was diagnosed schizophrenia at the age of 22. Currently, she is hospitalized due to psychotic decompensation. The patient was admitted with following daily dose therapy of: haloperidol 15 mg, biperiden 4 mg and diazepam 15 mg. During this hospitalization she developes muscle rigidity, tremor, hyperthermia, and laboratory results showed increase of enzimes CPK and LDH, so we started treatment of suspected malignant neuroleptic syndrome. After a treatment and recovery with complete withdrawal of all presented symptoms, our patient developed a malignant hypertermia that was resistant to all applicated medications. Our dilemma is whether presented symptoms of malignant hyperthermia are related to malignant neuroleptic syndrome or not?Disclosure of interestThe authors have not supplied their declaration of competing interest.

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T-wave inversion in the precordial leads: сardiac and non-cardiac causes

Kardiologiia ◽

10.18087/cardio.2020.5.n668 ◽

2020 ◽

Vol 60 (5) ◽

pp. 136-145

Author(s):

I. R. Tsoy ◽

I. P. Kolos

Keyword(s):

Pulmonary Embolism ◽

Differential Diagnosis ◽

Anterior Wall ◽

Left Ventricular ◽

Arrhythmogenic Cardiomyopathy ◽

Cardiac Memory ◽

T Wave ◽

Wave Inversion ◽

Threatening Condition ◽

Life Threatening

The T-wave inversion (TWI) is a common electrocardiographic finding. Causes for TWI are numerous and sometimes TWI may appear in life-threatening conditions. The aim of this review was to provide an up-to-date analysis of TWI, including i) definition and prevalence; ii) causes, and iii) differential diagnosis in benign TWI, reversible myocardial ischemia of the left ventricular anterior wall; takotsubo cardiomyopathy; subarachnoid hemorrhage; pulmonary embolism; right ventricular arrhythmogenic cardiomyopathy; and “cardiac memory”. The review presents practical electrophysiological criteria, which allow suspecting in time a life-threatening condition to choose an up-to-date treatment.

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Methaemoglobinaemia from Vagisil creme in a 50-year-old woman

BMJ Case Reports ◽

10.1136/bcr-2020-239697 ◽

2021 ◽

Vol 14 (3) ◽

pp. e239697

Author(s):

Sarah Cheyney ◽

Zachary Field ◽

Jacqueline Kropf ◽

Steve Carlan

Keyword(s):

Emergency Department ◽

Differential Diagnosis ◽

Topical Anaesthetic ◽

Over The Counter ◽

Perimenopausal Woman ◽

Threatening Condition ◽

Life Threatening

Methaemoglobinaemia is a life-threatening condition that results from increased methaemoglobin production. As methaemoglobin is unable to reversibly bind to oxygen potentially lethal hypoxia and functional anaemia can occur. Benzocaine can be used as a topical anaesthetic and can be found in many nonprescription preparations marketed for self-application. It is known to cause methaemoglobinaemia in rare cases but most reports describe the complication occurring during endoscopy procedures. Methaemoglobinaemia occurring after topical benzocaine use on the perineum of a perimenopausal woman is exceedingly rare. A 50-year-old woman with methaemoglobinaemia secondary to the perineal application of over-the counter Vagisil (benzocaine 20% and resorcinol 3%- an antiseptic and disinfectant, respectively) presented to the emergency department. She had been using Vagisil for severe, chronic vaginal itching. While methaemoglobinaemia secondary to excessive use of over-the-counter medications such as Vagisil creme is exceedingly rare, it should be included in the differential diagnosis.

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An approach to neuroleptic malignant syndrome from a clinical case

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.2374 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S631-S632 ◽

Cited By ~ 1

Author(s):

A. Gomez Peinado ◽

P. Cano Ruiz ◽

M.D. Sanchez Garcia ◽

S. Cañas Fraile ◽

M. Gonzalez Cano ◽

...

Keyword(s):

Neuroleptic Malignant Syndrome ◽

Clinical Case ◽

Medical Complication ◽

Neuroleptic Treatment ◽

Autonomic Nervous System Dysfunction ◽

Electrolyte Disturbances ◽

Starting Point ◽

Threatening Condition ◽

Life Threatening ◽

Competing Interest

IntroductionNeuroleptic malignant syndrome (NMS) takes place in patients in treatment with neuroleptics and it is potentially lethal, being important an early diagnostic and therapeutic approach.ObjectivesTo analyze from a clinical case the clinical and epidemiological features, and therapeutical approach to NMS.MethodReview of some articles in Mental Health journals and analysis of the following clinical case: 68-year-old woman with bipolar disorder, hospitalized in manic phase. Usual treatment: lithium, trazodone, quetiapine and asenapine. During the admission to hospital, the patient started presenting hyperthermia, sweating, electrolyte disturbances, limb rigidity, and elevation of CPK levels. The suspicion was NMS, so neuroleptics were stopped and fluids and dantrolene were initiated, with favorable evolution.ResultsThe discharge diagnosis was NMS. Neuroleptics were gradually reintroduced under vigilance. The patient is stable and has not had new complications. NMS is an uncommon (0.02% to 3% among patients taking neuroleptic agents), but life-threatening condition. Its symptoms are hyperthermia, autonomic nervous system dysfunction, limb rigidity, altered consciousness… The attendant infections, consume of lithium, dehydration, iron deficiency and sharp changes in neuroleptic treatment are predisposing factors. The withdrawal of neuroleptics is the key of the treatment. Benzodiazepines can improve the prognosis, and electroconvulsive therapy can be necessary if there is no response to previous measures.ConclusionsNeuroleptic malignant syndrome is a life-threatening medical complication we should try to avoid by a correct and careful use of neuroleptics. Additionally, it is important the early treatment, taking withdrawal of neuroleptics as the key starting point.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Sigmoid volvulus in children

BMJ Case Reports ◽

10.1136/bcr-2021-241869 ◽

2021 ◽

Vol 14 (5) ◽

pp. e241869

Author(s):

Merete Berthu Damkjaer ◽

Waqas Farooqui ◽

Inge Ifaoui ◽

Luit Penninga

Keyword(s):

Differential Diagnosis ◽

Ct Scan ◽

Sigmoid Volvulus ◽

Abdominal Discomfort ◽

Paediatric Patients ◽

Threatening Condition ◽

Life Threatening ◽

Abdominal Distress ◽

Emergency Resection

Sigmoid volvulus in paediatric patients is a rare but potentially life-threatening condition. Since 1940, only 100 cases have been reported. There are no consensual guidelines for juvenile sigmoid volvulus unlike in adults, where the condition and the treatment is well described. We report a case of a 12-year-old patient, who presented with uncharacteristic symptoms of mild abdominal discomfort and lack of passage of stool. A CT-scan showed a sigmoid volvulus and emergency resection was performed with placement of a colostomy. With this case, we want to emphasise juvenile sigmoid volvulus as a probable differential diagnosis when symptoms of abdominal distress and constipation occur.

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Malignant catatonia and neuroleptic malignant syndrome: How different/similar are they?

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.2407 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S640-S640 ◽

Cited By ~ 1

Author(s):

P. Sales ◽

M. Bernardo ◽

A. Lopes ◽

E. Trigo

Keyword(s):

Supportive Care ◽

Neuroleptic Malignant Syndrome ◽

Specific Treatment ◽

Hemodynamic Instability ◽

Psychotic Symptoms ◽

Muscle Rigidity ◽

Life Threatening ◽

History Of ◽

Competing Interest ◽

Malignant Catatonia

IntroductionCatatonia is a neuropsychiatric syndrome that appears in medical, neurological or psychiatric conditions. There are presentation variants: “malignant catatonia” (MC) subtype shares many characteristics with the neuroleptic malignant syndrome (NMS), possibly reflecting common pathophysiology.Objectives/methodsWe present a clinical vignette and review the literature available on online databases about MC/NMS.ResultsWe present a man, 41-years-old, black ethnicity, with no relevant medical history. He had two previous episodes compatible with brief psychosis, the last one in 2013, and a history of adverse reactions to low doses of antipsychotics. Since the last episode he was asymptomatic on olanzapine 2.5 mg id. He acutely presented to the Emergency Room with mutism, negativism, immobility and delusional speech, similar to the previous episodes mentioned and was admitted to a psychiatric infirmary, where his clinical condition worsened, showing muscle rigidity, hemodynamic instability, leukocytosis, rhabdomyolysis and fever. Supportive care was provided, olanzapine was suspended and electroconvulsive therapy (ECT) was initiated. After two months, he was discharged with no psychotic symptoms. He is still under ECT and no antipsychotic medication was reintroduced.Discussion/conclusionMany studies suggest that clinical or laboratory tests do not distinguish MC from NMS and that they are the same entity. These two conditions are life-threatening and key to treatment is a high suspicion level. There is no specific treatment; supportive care and stopping involved medications are the most widely used measures. ECT is a useful alternative to medication.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Neuroleptic Malignant Syndrome: A Review for Intensivists

Journal of Intensive Care Medicine ◽

10.1177/088506669400900502 ◽

1994 ◽

Vol 9 (5) ◽

pp. 227-234 ◽

Cited By ~ 3

Author(s):

Laura M. Prager ◽

Frederick H. Millham ◽

Stern A. Theodore

Keyword(s):

Risk Factors ◽

Intensive Care ◽

Diagnostic Criteria ◽

Neuroleptic Malignant Syndrome ◽

Critically Ill ◽

Critically Ill Patients ◽

Treatment Options ◽

Accurate Diagnosis ◽

Case Examples ◽

Life Threatening

Neuroleptic malignant syndrome (NAIS) is arare, potentially life-threatening disorder that results from the use of neuroleptics, a class of drugs that is being used with increasing frequency in intensive care units (ICUs). Unfortunately, critically ill patients typically have coexisting conditions that make accurate diagnosis of NAIS difficult and complicate treatment decisions. Diagnostic criteria, risk factors, and treatment options for NMS are discussed; case examples are provided.

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Paliperidone Inducing Concomitantly Syndrome of Inappropriate Antidiuretic Hormone, Neuroleptic Malignant Syndrome, and Rhabdomyolysis

Case Reports in Critical Care ◽

10.1155/2016/2587963 ◽

2016 ◽

Vol 2016 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Jaspinder Kaur ◽

Dileep Kumar ◽

Mostafa Alfishawy ◽

Ricardo Lopez ◽

Issac Sachmechi

Keyword(s):

Neuroleptic Malignant Syndrome ◽

Antidiuretic Hormone ◽

Health Care Providers ◽

Creatine Phosphokinase ◽

Liver Enzymes ◽

Antipsychotic Agent ◽

Muscle Rigidity ◽

Care Providers ◽

High Grade Fever ◽

Life Threatening

Paliperidone, an active metabolite of risperidone, is a new atypical antipsychotic agent. Syndrome of inappropriate antidiuretic hormone (SIADH), neuroleptic malignant syndrome (NMS), and rhabdomyolysis are the uncommon side effects of psychotropic drugs.We report a case of 35-year-old male with schizoaffective disorder who was admitted for acute-on-chronic exacerbation of his psychotic disorder for which intramuscular paliperidone 234 mg injection was given. Two days later, the patient developed hyponatremic seizures secondary to SIADH which was treated with hypertonic saline. On the third day, he developed high grade fever and severe muscle rigidity with raised creatine phosphokinase (CPK) and liver enzymes levels. He was treated with dantrolene 100 mg, bromocriptine 2.5 mg, and lorazepam 2 mg. Our patient required management of the three rare conditions following treatment with paliperidone. This case highlights the need for health care providers to be aware of the rare, potentially life threatening but preventable hyponatremia, NMS, and rhabdomyolysis as a possible adverse effect of paliperidone.

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Sudden cardiac arrest associated with myxedema coma due to undiagnosed hypothyroidism: a case report

BMC Endocrine Disorders ◽

10.1186/s12902-021-00894-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Asami Yoshinaka ◽

Masayuki Akatsuka ◽

Shuji Yamamoto ◽

Michiaki Yamakage

Keyword(s):

Cardiac Arrest ◽

Differential Diagnosis ◽

Physical Examination ◽

Sudden Cardiac Arrest ◽

Spontaneous Circulation ◽

Clinical Findings ◽

Neurological Dysfunction ◽

Myxedema Coma ◽

Threatening Condition ◽

Life Threatening

Abstract Background Myxedema coma, which occurs due to hypothyroidism, is a rare and life-threatening condition. Some patients have hemodynamic dysfunction, which consequently leads to cardiac arrest. The rarity of this condition makes it difficult to determine the cause of cardiac arrest. It is important to diagnose myxedema coma based on clinical findings, including physical examination and laboratory parameters. We present a case of undiagnosed and untreated hypothyroidism that initially caused myxedema coma and then led to cardiac arrest. Case presentation A 56-year-old woman who had no medical history was transferred to our hospital for the management of return of spontaneous circulation due to sudden cardiac arrest. Findings of laboratory tests revealed that she had hypothyroidism. On physical examination, she was found to have a puffy face, thin eyebrows, and severe systemic non-pitting edema. Therefore, the patient was clinically diagnosed with myxedema coma, which was the cause of cardiac arrest. She was treated with thyroid hormone and hydrocortisone, resulting in improvement in her general condition, except for the neurological dysfunction. Conclusions This case suggests that myxedema coma is caused by undiagnosed and untreated hypothyroidism, leading to sudden cardiac arrest. Our findings are useful in the differential diagnosis of hypothyroidism based on characteristic physical examination findings. Clinicians should be aware of the differential diagnosis of myxedema coma based on findings from physical examination and laboratory testing of thyroid function, and the treatment should be started immediately.

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Pediatric Gastrointestinal Emergencies

Pediatric Emergencies ◽

10.1093/med/9780190073879.003.0041 ◽

2020 ◽

pp. 501-524

Author(s):

Joshua Easter

Keyword(s):

Differential Diagnosis ◽

Gastrointestinal Disease ◽

Signs And Symptoms ◽

Diagnostic Information ◽

Atypical Presentation ◽

Significant Morbidity ◽

Diagnostic Features ◽

Gastrointestinal Problems ◽

Pediatric Presentation ◽

Delays In Diagnosis

Many conditions affect the gastrointestinal tract in children. Compared with adult gastrointestinal problems, gastrointestinal problems in children present with unique signs and symptoms. In younger children, it can be particularly difficult to elicit reliable diagnostic information from the history and physical examination. Pediatric gastrointestinal disease often requires surgical intervention, and delays in diagnosis may lead to significant morbidity and mortality. The differential diagnosis depends on age. Presentation also varies with age, and many conditions are unique to children. This chapter discusses important gastrointestinal emergencies. The classic pediatric presentation, atypical presentation, diagnostic features, treatment, and potential complications for these emergencies are also detailed.

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