Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Conclusion
Case Report
An 18-year-old
female with a history of mental illness presents to her local physician with
complaints of worsening insomnia for the last 3 days. She has a recent history
of intermittent insomnia for the last three months. She was treated with
long-acting haloperidol and was sent home. Two days later, the patient presents
o the emergency department of a tertiary care hospital with intense lower back
pain, jaw stiffness and fluctuating fever. Patient was stabilized, given
antibiotics and baseline investigations were done including a CT scan; the
patient was admitted to the medical ward. All of the results were within normal
limits and any infectious pathology was ruled out. Patient was given analgesics
(NSAIDs and Acetaminophen) for pain relief. On her 4th hospital day, she
developed a new onset of non-epileptic, jerky, seizure-like episodes 4-5 times
per day, each episode lasting 4-5 minutes followed by intense back pain,
associated with headache and increased body stiffness. Patient was referred to
the psychiatry ward to rule out dissociative symptoms; blood creatine
phosphokinase (CPK) measured 1257mg/dl. After taking a careful history,
examination and investigation, a provisional diagnosis of NMS with dissociative
overlay was made and treatment was started accordingly. Patient was given
bromocriptine, amantadine, lorazepam and fluoxetine. After one week of
treatment her body stiffness improved but the patient still complained of
left-sided back pain and headache. Individual psychotherapy sessions over the
next 2 to 3 weeks resolved all of her remaining symptoms and patient was
discharged on medication.
Discussion
To date NMS has
been diagnosis of exclusion. Levenson et al. [7] proposed a set of diagnostic
criteria (Table 1) for NMS; major criteria of fever, rigidity, and elevated CPK
and minor criteria of tachycardia, abnormal arterial pressure, tachypnea,
altered consciousness, diaphoresis, and leukocytosis. The presence of three
major criteria or two major and four minor criteria with a supportive clinical
history would suggest a diagnosis of NMS. These diagnostic criteria have not
seen universal adoption, though all three major criteria were present in our
patient. The rarity of this adverse drug reaction (ADR) has resulted in less research
in this field and hence most treatment has been based on case reports. Early
diagnosis is crucial for the treatment of NMS as delay in diagnosis is
associated with increased morbidity and mortality. Guerrera et al convened a
multispecialty panel of 17 physicians to assign a priority score for various
aspects of history, examination, and test results that add up to 100. To date,
however, no total score has been tested or verified as diagnostic of NMS.
Unfortunately, a lack of a universal diagnostic criteria as well as uncommon
and atypical presentations often result in the delay in diagnosis and
treatment. Four symptoms (muscle rigidity, hyperthermia, altered mental status,
autonomic instability) and elevation of CK are considered diagnostic of NMS by most
physicians. Atypical NMS, therefore, would be any presentation lacking 1 of
these signs and symptoms. Atypical NMS can progress to typical NMS if the
missing signs and symptoms appear in the patient at a later time [8]. In our
case, the patient presented after two days of treatment with a long-acting
high-potency antipsychotic with atypical symptoms. This patient had the four
cardinal symptoms of a typical NMS presentation. However, jaw stiffness and
lower back pain were the main presenting features of the patient in the ER and
the lack of a detailed history and physical examination made it difficult for
the physicians to consider NMS on the differential diagnosis. An article
published by Oruch et al. also emphasized the overlapping presentation of NMS with
other pathologies with similar clinical picture resulting in difficulties with
diagnosis. These pathologies include serotonin syndrome, malignant
hyperpyrexia, malignant catatonia and clozapine-induced hyperpyrexia among
others [9].
The experience of
the physician as well as the high suspicion of NMS can make the diagnosis
possible in a timely manner. A study done by Margetic et al emphasized the
importance of physician expertise noting that a detailed history and
appropriate physical examination aid in the diagnosis. Non-expert physicians
can easily misinterpret NMS as being symptoms of an untreated medical illness
[10]. In our case, the atypical presentation along with a low suspicion of NMS
by the physician led to the delay in diagnosis and treatment. As the definite
diagnostic criteria is lacking due to the various clinical presentations,
further studies should be conducted in this regard to find the most common
atypical presentations along with a standard treatment plan for NMS. This case
is the first of its kind presented in Pakistan and further research in this
field would help lead to more appropriate diagnostic and management plans.
This case report highlights the difficulty of reaching a diagnosis in patients with overlapping dissociative symptoms and underlying mental illness who presenting with early signs and symptoms of neuroleptic malignant syndrome. A careful history is invaluable to reach a rapid diagnosis of NMS. Given the potentially deadly outcome of this condition, early diagnosis and treatment are necessary to prevent the associated morbidity and mortality of this ADR. The patient’s NMS and mental illness should be treated simultaneously with care to avoid further use of neuroleptic medications. Given the infrequent nature of this condition, this case report will be a valuable addition to the limited literature of NMS.
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