Objective: We describe four cases of Neuroleptic Malignant Syndrome (NMS) with high mortality rates, despite decreased reports of the disease in the past decades.

Background: NMS is a rare, potentially lethal neurological emergency which occurs as a reaction to neuroleptics. The patophysiology behind the condition remains unknown. Men has higher prevalence of NMS due to higher tendency of the disease and/or neuroleptic use.

Method: We report four patients, which is A 23-year old man, A 17-year-old man, A 33-year-old woman and A 54-year-old man. All patients present with classic signs of NMS, which includes altered mental status, hyperthermia, motoric sign (rigidity) and autonomic instability (hypertension and/or tachycardia). All patients had a history of antipsychotic drugs use due to varied psychiatric conditions. Increase of Creatine Kinase (CK) enzymes, a cardinal laboratory finding in NMS, also occurs in all patients. Except for the third case, where cerebrospinal liquid test results were normal, brain imaging showed no signs of a central nervous system (CNS) infection. Unfortunately, despite treatments using ergot derivative bromocriptine and lorazepam on all patients, three of our patients except patient number four passed away.

Results: Despite reports stating that NMS is rare, we found several NMS patients with a very classic presentation in our hospital. Diagnosing NMS is a challenge due to its clinical similarity with CNS infections and other neurological disorders. A careful history of neuroleptics use is very important, which can be seen in all of our patients. Lumbar punction and brain imaging should also be done to exclude the possibility of infections and other intracranial pathology. NMS also carries a high rate of mortality (up to 55%) and had a higher prevalence in men, which can also be seen in our patients. An increase of CK enzymes may also help in diagnosing NMS, as we could see that all of our patients had an increased level of CK-NAC and CK-MB. Neuroleptics termination is the first step in the management of NMS. Pharmacological management includes Dantrolene, a muscle relaxant, Bromocryptine, and/or benzodiazepines. Due to lack of Dantrolene in our hospital, we treat our patients with Bromocryptine and Lorazepam/ diazepam.

Conclusion: NMS should be highly considered in patients presenting with neurological symptoms and a history of neuroleptic uses due to its high mortality.

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