Abstract
A 34-year-old woman was hospitalized with a DSMIV diagnosis of bipolar disorder, manic episode, with psychotic features [1]. She was given zuclopenthixol HCl 10 mg/day during the first 17 days of her admission. Thioridazine 50–100 mg/day orally was added on day 17, to decrease psychotic symptoms. Zuclopenthixol acetate 50 mg intramuscularly was also given on days 3, 7 and 21. On day 22, the patient developed muscular rigidity, dysarthria, coarse tremor, incontinence, imbalance, dysphagia, mutism, fever (up to 42°C), tachycardia (up to 140 beats/min), diaphoresis, and delirium. Following an extensive medical work-up, a diagnosis of neuroleptic malignant syndrome (NMS) was made according to DSM-IV [1].
All antipsychotic medications were discontinued. Bromocriptine, 15 mg orally daily, was started following 8 days of symptomatic treatment. Electroconvulsive therapy was started on the same day, to manage the patient's psychosis (seven sessions in total).
Laboratory findings included significant leukocytosis (up to 24 300/mm3) and elevation of serum creatine kinase (up to 2841 U/L). There was a decrease in serum iron, from 55 mg/dL on admission, to a nadir of 26 mg/ dL on day 14 of NMS. Haemoglobin (Hb) levels also decreased, from 10.6 g/dL on admission, to a low of 6.8 g/dL on day 14 of NMS. Serum ferritin increased from 3.1 mg/dL on admission, to a peak of 67.43 mg/dL on day 18 of NMS. There also was a rise in sedimentation rate, from 22 mm/h on admission, to a peak of 92 mm/h on day 21 of NMS (Figure 1).
Changes observed in acute phase reactants during the course of neuroleptic malignant syndrome-NMS in a case with bipolar illness (ferritin, mg/dL; sedimentation, mm/h; serum iron, mg/dL).
As the patient's mental status and physical symptoms gradually improved during the following weeks, her biochemistry profile returned to the levels recorded at admission. Full recovery took 14 days. On day 39 of NMS, Hb was 10.5 g/dL; serum iron, 76 mg/dL; ferritin, 29.41 mg/dL; and sedimentation rate was 26 mm/h (Figure 1).
Serial biochemistry findings in this case support the notion that NMS may represent an acute phase reaction [2, 3]. The potential benefit of anti-inflammatory medications in NMS needs to be investigated.