Neuroleptic malignant syndrome associated with abrupt withdrawal of anticholinergic agents

Oral manifestations are present in about 3-5% of cases of non-Hodgkin's lymphoma (NHL) and oral lesions are only rarely the initial manifestations of NHL. A case is presented of an 80-year-old patient with a NHL of the tongue, without visceral or lymph node involvement. The diagnosis of NHL can be made only by biopsy. The prognosis of NHL seems to be related to the tumour stage, tumour aggressiveness and response to treatment: the oral lesions appear to respond quite well to irradiation.     

Neuroleptic malignant syndrome associated with multiple joint dislocations in a trauma patient

The structure of the O-antigenic polysaccharide from Escherichia coli O141 has been determined. NMR spectroscopy and sugar and methylation analyses were the principal methods used. The sequence of the sugar residues could be determined by NOESY and heteronuclear multiple-bond connectivity (HMBC-) NMR experiments. The polysaccharide is composed of pentasaccharide repeating units with 1 O-acetyl group/repeating unit. The following structure, where Rha is 6-deoxymannose is concluded: carbohydrate sequence [see text].     

Neuroleptic malignant syndrome: a review

Experiments were performed in a tissue microwave-equivalent phantom gel to quantitatively examine the volumetric heating produced by a microwave antenna with a peripheral cooling system for the transurethral prostatic thermotherapy. Based on previous research, expression for the specific absorption rate (SAR) of microwave energy in the gel was extended to three dimensions, which includes its dependence on radial, angular, and axial direction. A theoretical heat transfer model was developed to study the temperature distribution in the gel by introducing this proposed SAR expression. The parameters in this expression and the convection coefficient due to the chilled water running around the antenna were determined using a least-square residual fit of the theoretical temperature predictions to the experimentally measured steady-state temperature field within the gel. The analytical expression of the three-dimensional SAR distribution obtained in this study will help provide a better understanding of the microwave heating pattern in the prostatic tissue and, thus, to aid in designing improved applicators. It can also be used in the future as an accurate input to heat transfer models which predict temperature distributions during the transurethral microwave thermotherapy.     

Neuroleptic malignant syndrome and clozapine monotherapy

OBJECTIVE: This report identifies neuroleptic malignant syndrome (NMS) occurring on a steady state dosage of clozapine monotherapy. CLINICAL PICTURE: An outpatient presented with a recent history of stiffness and soreness of his legs, dizziness, polydipsia, polyuria, abdominal and chest pains. After admission to a general hospital, further symptomatology was identified including: pallor, diaphoresis, nausea, confusion, agitation, decrease in normal reflexes, minimally reactive pupils and rigid limbs. TREATMENT: Intravenous (I/V) diazepam was administered but failed to decrease the agitation and confusion. He was sedated with the administered of I/V droperadol, intubated and placed on a ventilator with circulatory supports for 4 days. OUTCOME: On day five he was extubated and transfered to a medical ward. All laboratory values had returned to normal values by this time. The patient was subsequently discharged. CONCLUSIONS: Neuroleptic malignant syndrome can occur at any stage of clozapine treatment, and the patient can be rechallenged after such an episode. This person was rechallenged and after 6 months of treatment has suffered no further recurrence of NMS.     

Neuroleptic malignant syndrome in the acquired immunodeficiency syndrome

Patients infected by the human immunodeficiency virus are predisposed to many infectious and noninfectious complications and often receive a variety of drugs. Furthermore, they seem to have a particular susceptibility to idiosyncratic adverse drug reactions. It is therefore surprising that only a few cases of the neuroleptic malignant syndrome have been described in patients with the acquired immunodeficiency syndrome. A high index of suspicion is required to diagnose the neuroleptic malignant syndrome in these patients, as its usual manifestations, including fever and altered consciousness, are frequently attributed to an underlying infection.     

Neuroleptic malignant syndrome in the elderly: description of 4 patients

The neuroleptic malignant syndrome is a fulminant, life-threatening reaction to neuroleptic medication. It is characterized by fever, rigidity, autonomic disfunction and fluctuating consciousness. Usually described in young adults with psychiatry illnesses, its presentation in an elderly population has received scant attention in medical literature. We describe the clinics and evolutive characteristics of 4 cases of this syndrome in elderly which a mean age of 78 years. We emphasise about the existence of a brain organic illness with dementia as a predisposing factor, and the correct evolution of the showed cases in probably relation with measures and drug therapy.     

Neuroleptic malignant syndrome and mivacurium: a safe alternative to succinylcholine?

Neuroleptic malignant syndrome (NMS) and malignant hyperthermia (MH) may have a common pathogenic mechanism; therefore, it has been suggested that known triggering agents for MH (such as succinylcholine) should be avoided in patients with NMS. Electroconvulsive therapy (ECT) continues to play a major therapeutic role in contemporary psychiatry, and succinylcholine has been the muscle relaxant of choice in attenuating violent muscle contractions induced by ECT. Mivacurium is a non-depolarizing muscle relaxant with a relatively rapid onset and a short duration of action, and to date it has been proved safe in MH-susceptible patients. In this case report, following succinylcholine use during ECT, a patient with NMS developed an increase in temperature and serum creatine kinase (CK) level, possibly due to an MH reaction. Since the patient's mental status necessitated further ECT, mivacurium was administered during subsequent treatment and resulted in effective attenuation of muscle contractions without elevation of patient temperature or CK levels. In addition, there was no marked prolongation of the anaesthetic. Mivacurium is a suitable agent for patients with NMS undergoing ECT, as it has not been associated with precipitation of an MH response.     

Cardiac arrhythmia associated with malignant neuroleptic syndrome: description of 2 clinical cases

Malignant neuroleptic syndrome (alteration of consciousness, muscle rigidity and hyperthermia) is a potentially lethal condition, due also to its life-threatening complications. In particular, hypokinetic and hyperkinetic arrhythmias can be rare and severe early manifestations of this illness, and they deserve a careful approach because of their drug-refractoriness. Arrhythmias associated with the malignant neuroleptic syndrome depend on various mechanisms: neurotransmitter receptor blockades typical of neuroleptic drugs, clustered lipid droplets among the cardiac myofibrils and possible electrolytic disorder due to diaphoresis. The two cases described here presented hypokinetic and hyperkinetic (supraventricular and ventricular) arrhythmias. The arrhythmias, which failed to respond to antiarrhythmic drugs, were temporarily suppressed by DC shock, over-drive pacing and correction of electrolytic imbalance. In case 1, prolonged bromocriptine treatment was required. Complete wash-out of the causative agents resulted in lasting regression of arrhythmias. In conclusion, a correct treatment and a favourable outcome of this syndrome can be achieved only through early diagnosis.     

Hemostatic evaluation of a patient with haloperidol-induced neuroleptic malignant syndrome associated with disseminated intravascular coagulation

A 94-year-old man who had been admitted to our hospital for the treatment of senile dementia and restless behavior exhibited consciousness disturbances, acute respiratory failure, high fever, and thrombocytopenia the day after receiving haloperidol as prescribed by a psychiatrist. On the fourth day following administration of haloperidol, acute renal failure with rhabdomyolysis and disseminated intravascular coagulation (DIC) developed in the patient, who was accordingly given a diagnosis of haloperidol-induced neuroleptic malignant syndrome (NMS) associated with DIC. He was then given heparin and antithrombin III, and his DIC symptoms improved soon thereafter. Elevated plasma levels of tissue factor and tumor necrosis factor-alpha (TNF-alpha) were sustained during this therapy course. Other cytokines, including interleukin IL-1 beta, IL-2 and IL-6, were not elevated. There are activation of extrinsic coagulation and an elevated level of TNF-alpha during acute renal failure and rhabdomyolysis associated with NMS, which is thought to trigger the onset of DIC.     

Mania-like syndrome in a patient with chronic schizophrenia during olanzapine treatment

The first reported case of Clostridium septicum myonecrosis in an adult with aplastic anemia is described. The patient presented with sepsis, a parapharyngeal abscess that necessitated emergent intubation, and severe intravascular hemolysis attributed to clostridial alpha-toxin production. Despite prompt recognition and treatment, the patient died of his infection. C. septicum myonecrosis should be considered in any immunocompromised patient with sepsis, especially when accompanied by evidence of multiple sites of tissue infection.     

Drug utilization patterns and outcomes associated with in-hospital treatment with risperidone or olanzapine

This study compared the drug-utilization costs and indicators of clinical outcomes associated with the use of risperidone and olanzapine in a hospital setting. We conducted a nonrandomized, retrospective chart review of consecutive patients identified as presenting with psychotic symptoms on inpatient wards at Riverview Hospital in British Columbia and given either risperidone or olanzapine as their first new drug after reassessment (n = 30 per treatment group). Data were collected for up to 120 days. No significant differences were observed between groups in terms of sex, age, duration of illness, or diagnosis. The mean dosage of risperidone for responders was 4.89 +/- 2.56 mg/d, whereas that for olanzapine was 17.19 +/- 3.88 mg/d. The associated daily drug-acquisition costs were significantly different, at CA$4.69 for risperidone and CA$11.52 for olanzapine. Notes in patient charts indicated that a significantly greater proportion of risperidone-treated patients (60.0%) than olanzapine-treated patients (26.7%) responded to therapy, as indicated by improvement in at least one target symptom (P < 0.01). Forty percent of patients initially treated with risperidone were discharged on their original therapy, compared with 13.3% of patients treated with olanzapine (P < 0.05). These results were not substantially affected by correction for markers of illness severity or treatment resistance. Overall, no significant differences in side effects were recorded in the patient records of the two groups. Within this cohort of patients, risperidone treatment was associated with lower drug-acquisition cost and better treatment outcomes than olanzapine.     

Kabuki make-up syndrome associated with West syndrome

A Japanese boy with Kabuki make-up syndrome associated with West syndrome is reported. He developed periodic tonic spasms at 6 months of age while his electro-encephalogram also revealed hypsarrhythmia. Although only a few previously reported cases of Kabuki make-up syndrome have been associated with epilepsy, it is likely that epileptic seizures are another primary feature of Kabuki make-up syndrome.     

Strongyloidiasis associated with nephrotic syndrome

We report a nephrotic syndrome patient with eosinophilia who developed ileus, epigastralgia and malabsorption due to strongyloidiasis which became symptomatic by steroid therapy. The patient was then treated with thiabendazole and recovered. A percutaneous renal biopsy revealed minimal change nephrotic syndrome. This renal injury may be brought on by severe infection of Strongyloides stercoralis. It is important to rule out strongyloidiasis prior to corticosteroid therapy to patients from eosinophilia endemic areas.     

Churg-Strauss syndrome associated with zafirlukast

The leukotriene receptor antagonist zafirlukast (Accolate; Zeneca Pharmaceuticals; Wilmington, Del) recently was approved for use as maintenance therapy for persistent asthma. This new product has been well received due to convenient dosing and relatively few side effects. Based on initial success with this product, it is likely that similar compounds will be available for use in the near future. In this report, a case is described of a 47-year-old white man with moderate persistent asthma in whom Churg-Strauss syndrome developed while he was receiving zafirlukast therapy. Acute respiratory insufficiency, arthralgia, and prominent rash developed which required hospitalization. The patient's symptoms rapidly reversed following discontinuation of zafirlukast therapy and administration of systemic corticosteroids. Although the incidence of Churg-Strauss syndrome associated with zafirlukast therapy is rare, this case report illustrates steps that may be taken to diagnose quickly and treat this life-threatening condition should it occur.     

Myoglobinuria, malignant hyperthermia, neuroleptic malignant syndrome and serotonin syndrome

This article presents an overview of the causes and manifestations of myoglobinuria and provides criteria for its diagnosis and management. The article also reviews neuroleptic malignant syndrome, malignant hyperthermia, and serotonin syndrome, all of which could cause rhabdomyolysis and myoglobinuria.     

Evans'' syndrome associated with Graves'' disease

A 36-year-old woman who had had Graves' disease for 6 years was admitted with severe thrombocytopenia. Evans' syndrome was diagnosed. The patient's family history showed multiple cases of Graves' disease but no cases of Evans' syndrome. Both conditions in this patient improved with corticosteroid and thiamazole therapy. Several autoimmune antibodies were found, but a common autoimmune mechanism was not clearly shown. Although the combination of Graves' disease and Evans' syndrome had not occurred previously in her family, genetic factors may play an important role in the pathogenesis of both conditions.