A 13-year-old girl with alteration of consciousness and muscular rigidity (2/2)
Prepared by...
Kanokwan Ruananukun, M.D.
Kamornwan Katanyuwong, M.D
Orawan Louthrenoo, M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University

Diagnosis:
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1. Neuroleptic malignant syndrome (NMS)
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 2. Underlying psychiatric disorder : major depressive disorder (MDD)
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 3. Serotonin syndrome
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 4. Juvenile parkinson disease

Managements:
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Discontinued antipsychotic drugs
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 Supportive and symptomatic treatments
  - Record vital sign, neuro sign and urine output
  - EKG Monitoring
  - Adequate hydration (IV fluid)
  - Temperature control by paracetamol q 4 hr, tepid sponge
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 Medications :
  - Bromocriptine (2.5 mg) 1 tab oral tid, pc
  - Diazepam (5 mg) 1 tab oral tid,pc
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 Consult pediatric neurologist and psychiatrist
Course in the hospital:
  - Muscular rigidity was gradually subsided after discontinuation of haloperidol and dose titration of bromocriptine plus diazepam.
  - The level of total CK was followed once daily. Maximum total CK level was 963 U/L on the 4th day of admission and then it decreased gradually.
  - No other complications of neuroleptic malignant syndrome such as rhabdomyolysis or autonomic instability.
  - The consciousness was back to normal and the patient was transferred to psychiatric department on the 7th day of admission for treatment underlying psychiatric disorder.
Discussion:
 
> Neuroleptic malignant syndrome (NMS) is a serious and life-threatening adverse reaction of antipsychotic medication. It is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.
> The incidence of NMS varies but it is approximately 0.2% in those treated with neuroleptics.
> Pathophysiology involves with the reduction in dopaminergic activity in the central nervous system. Blockade of dopamine neurotransmission in the striatum and hypothalamus results in muscular rigidity and altered thermoregulation, respectively.
> The diagnosis of NMS is based on clinical features that associated with the use of antipsychotic medication. Additional findings included laboratory evidences of muscle injury. (e.g. elevated blood creatinine phosphokinase, aminotransferase and lactate dehydrogenase)
> The most important intervention is to discontinue the antipsychotics, symptoms will resolve within 1-2 weeks. During the course of NMS, aggressive supportive treatments are aimed at preventing further complications and maintaining organ function.
> The pharmacotherapy has an uncertain role in treatment of NMS.
  - Dopamine agonist : bromocriptine, amantadine
  - Skeletal muscle relaxant : dantrolene, diazepam
References::
1.

Mancini MC, Deshpande GG. Neuroleptic malignant syndrome. 2008 [updated 9 Dec 2008; cited]; Available from: http://emedicine.medscape.com/article/907949-overview.
2.

Rodnitzky RL. Drug-induced movement disorders in children. Seminars in Pediatric Neurology. 2003;10:80-7.
3.
Smith FA, Wittmann CW, Stern TA. Medical complications of psychiatric treatment. Crit Care Clin. 2008;24:635-56.
4. Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-6.
5. Tonkonogy J, Sholevar DP. Neuroleptic malignant syndrome. 2009 [updated 7 May 2009; cited]; Available from: http://emedicine.medscape.com/article/288482-overview.