Objective: To report a case with re-emerging neuroleptic malignant syndrome (NMS) without re-introduced neuroleptic drugs.

Background: Neuroleptic Malignant Syndrome (NMS) is a potentially fatal idiosyncratic reaction, mostly associated with neuroleptics drugs. A complete resolution is usually reached within 1-week. Approximately 30% of NMS cases had recurrent episodes when the neuroleptic being re-introduced. The recurrence without any re-introducing drugs has never been reported.

Method: A 51-year-old male paranoid schizophrenia patient was admitted to the emergency department due to lower limb tremor, repetitive blinking and rigidity 3 days before admission. On admission, he looked disoriented with elevated blood pressure 170/100 mmHg and heart rate 120x/min. Serum creatinine phosphokinase (CPK) was 796.5 U/L. Six months ago, he started to receive monthly haloperidol decanoate injection 50 mg as additional to risperidone 2 mg bid and trihexyphenidyl 2 mg bid. The patient was diagnosed with NMS and treated with bromocriptine. He had to be discharged 1 month later due to symptoms fluctuations. Three weeks later, he was re-admitted with same symptoms acompanied by 38°C, blood pressure 190/95 mmHg, heart rate 140x/min and rigidity. The serum CPK was 2.703 U/L and leukocyte 12.140/Ul.

Results: This patient was diagnosed with NMS due to the previous history of high dose neuroleptic injections with rigidity, altered mental status, autonomic dysfunction, along with elevated CPK. There was a dramatic improvement after bromocriptine therapy, but he had several episodes of exacerbation that need up-titration dose. Since discharged, he discontinued bromocriptine and the symptoms re-emerged 3 weeks later even without any re-introduced of neuroleptic agents. We proposed that the long-acting properties of haloperidol decanoate injection, which uses sesame oil vehicle to ensure the slow and sustained release of active components, was responsible for the re-emerging symptoms, due to unknown metabolism errors.

Conclusion: This case report shows that re-emerging NMS without any re-introduced neuroleptic drugs may be possible due to long-acting properties of neuroleptics injection. It is important for clinicians to be aware that the long-acting typical neuroleptic injection could cause prolonged effect to have an early identification and intervention

References: 1. Blanco LG, Prada HG, Santamarina S, Trevino LJ, Bobes J. Recurrence of neuroleptic malignant syndrome. Actas Esp Psiquiatr 2013;41(5):314-8. 2. Pelonero AL, Levenson JL, Pandurangi AK. Neuroleptic malignant syndrome: a review. Psychiatr Serv 1998;49(9):1163-1172. 3. Stubner S, Rustenbeck E, Grohmann R, et al. Severe and uncommon involuntary movement disorders due to psychotropic drugs. Pharmacopsychiatry 2004;37(1):S54-S64. 4. Strawn JR, Keck PE Jr, Caroff SN: Neuroleptic malignant syndrome. Am J Psychiatry 2007;164:870–876. 5. Panagariya A, Sharma B, Singh R, Agarwal V, Dev. The neuroleptic malignant syndrome: A report of 14 cases from North India. Neurology India 2007;55(2):166-168. 6. Ouyang Z, Chu L. A case of recurrent neuroleptic malignant syndrome. Shanghai Archives of Psychiatry 2013;25(4). 7. Neuroleptic Malignant Syndrome. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association;1994:739-742. 8. Kumar S, Simlai J, Chaudhury S, Kumari R. Postinjection delirium/sedation syndrome with haloperidol decanoate injection. Pravara Med Rev 2016;8(3). 9. Berman B. Neuroleptic Malignant Syndrome: a review for neurohospitalists. Neurohospitalist 2011;1(1):41–47. doi: 10.1177/1941875210386491. 10. DeFronzo RA, Bromocriptine: a sympatholytic, D2-dopamine agonist for the treatment of type-2 diabetes. Diabetes Care 2011; 34(4):789-794. https://doi.org/10.2337/dc11-0064.

« Back to 2019 International Congress

MDS Abstracts - https://www.mdsabstracts.org/abstract/re-emerging-neuroleptic-malignant-syndrome-nms-without-re-introduced-neuroleptic-in-a-schizophrenia-patient-a-case-report/