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Neuroleptic malignant syndrome: an easily overlooked neurologic emergency

Authors Oruch R, Pryme IF, Engelsen BA, Lund A

Received 29 July 2016

Accepted for publication 21 October 2016

Published 16 January 2017 Volume 2017:13 Pages 161—175


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Roger Pinder

Ramadhan Oruch,1 Ian F Pryme,2 Bernt A Engelsen,3 Anders Lund4

1Department of Pharmacology and Toxicology, School of Pharmacy, Benghazi University, Benghazi, Libya; 2Department of Biomedicine, 3Department of Clinical Medicine, Section of Neurology, 4Department of Clinical Medicine, Section of Psychiatry, University of Bergen, Bergen, Norway

Abstract: Neuroleptic malignant syndrome is an unpredictable iatrogenic neurologic emergency condition, mainly arising as an idiosyncratic reaction to antipsychotic agent use. It is characterized by distinctive clinical features including a change in mental status, generalized rigidity, hyperpyrexia, and dysautonomia. It can be lethal if not diagnosed and treated properly. Mortality and morbidity attributed to this syndrome have recently declined markedly due to greater awareness, earlier diagnosis, and intensive care intervention. In most cases, the syndrome occurs as a result of a rapid increase in a dose of neuroleptic, especially one of the long-acting ones. Pathophysiology behind this syndrome is attributed to a dopamine receptor blockade inside the neurons rendered by the offending drug and excessive calcium release from the sarcoplasmic reticulum of skeletal myocytes. Laboratory tests, although not diagnostic, may assist in assessing the severity of the syndrome and also the consequent complications. The syndrome has been described in all age groups and occurs more in males than in females. Genetics appears to be central regarding the etiology of the syndrome. Stopping the use of the offending agent, cold intravenous fluids, and removal of the causative agent and its possible active metabolites is the cornerstone of treatment. Periodic observation of psychotic patients recently started on antipsychotic medications, especially those being treated with depot preparations, may aid to an early diagnosis of the syndrome and lead to early treatment.

Keywords: neuroleptic malignant syndrome, dopamine receptors, rhabdomyolysis, renal shutdown, hyperpyrexia, sarcoplasmic reticulum

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