Advanced Skeletal Muscle Mass Reduction (Sarcopenia) Secondary to Neuromuscular Disease.

We describe a young male patient chronically on a ventilator secondary to decreased mobility from amyotrophic lateral sclerosis (ALS). He had both a tracheostomy for breathing and percutaneous endoscopic gastrostomy (PEG) for feeding. Using 24-hour urinary creatinine excretion data, we calculated an estimate of skeletal muscle (SM) mass. SM mass was indexed to height and weight to obtain the SM index. The SM index is used as a determinant to define sarcopenia. From the data, we found that this patient had the smallest SM index ever recorded at 2.2 kg/m2, consistent with extremely advanced sarcopenia. As a comparison, "severe" sarcopenia in a male is defined as a SM index ≤ 8.5 kg/m2. This method can be used in ICU patients to evaluate for sarcopenia which is a predictive marker for mortality.

Room-temperature thermodilution cardiac output. Central venous vs side port.

OBJECTIVE: To assess the accuracy of room-temperature thermodilution cardiac output measurements from the side port (SP) of the introducer catheter through which the pulmonary artery flotation catheter is inserted. DESIGN: Central venous port (CVP) cardiac output measurements were compared with SP cardiac output measurements using the same right-heart catheter. SETTING: The general intensive care unit of the Hospital for Joint Diseases, Orthopedic Institute, New York. PATIENTS: Thirty one orthopedic patients with 31 different right-heart catheters placed in the right internal jugular or right subclavian position were evaluated. INTERVENTION: Four injections of 10 ml of normal saline solution at room temperature were made through each port; the results of the last three injections were averaged. Cardiac output determinations from both ports were completed in less than 10 min. The order of port injection was random. RESULTS: A significant difference was noted between cardiac output determinations from the two ports (p < 0.001, paired Student's t test) with the SP slightly overestimating thermodilution cardiac outputs by 6.34 +/- 8.38 percent compared to the CVP. A significant correlation was noted between both ports (r = 0.97, p < 0.001) with the linear regression line starting at the origin (y intercept not significantly different from zero) with a slope (1.07) significantly greater than 1. CONCLUSION: If the proximal CVP becomes nonfunctional, room-temperature thermodilution cardiac outputs from the SP can be used with the understanding that a slight overestimation of cardiac output will occur.

Pneumococcal bacteremia with pneumonia. Mortality in acquired immunodeficiency syndrome.

OBJECTIVE: To compare mortality due to bacteremic pneumococcal pneumonia in patients with acquired immunodeficiency syndrome (AIDS) vs (control) patients without human immunodeficiency virus (HIV) infection. Non-AIDS patients with HIV infection were incidentally tabulated as a separate group. DESIGN: A two-year retrospective study. SETTING: Inpatients of St. Clare's Hospital, a community hospital in New York City. PATIENTS: Forty-nine patients had 50 separate episodes with at least one positive blood culture for Streptococcus pneumoniae (all were penicillin-sensitive) and pneumonia on chest roentgenogram. Twenty-four patients had no HIV infection, 14 patients had AIDS, and 11 patients with 12 bacteremic episodes were HIV-positive without AIDS. INTERVENTIONS: Treatment for pneumonia was determined by the patient's individual physician. MEASUREMENTS AND MAIN RESULTS: AIDS patients with pneumonia had a mortality of 57.1 percent (8/14), which was significantly higher than the 25 percent (6/24) seen in patients without HIV infection (p less than 0.025, two-sample test for independent proportions). Septic shock, usually occurring within the first five days of hospitalization, was the primary cause of death, occurring in six of eight AIDS patients and six of six patients without HIV infection. If the mortality in the first five days of hospitalization was excluded, the mortality would drop to 33.3 percent in the AIDS population and 5.3 percent in patients without HIV infection. Eleven HIV-infected patients without AIDS survived 12 episodes of bacteremic pneumococcal pneumonia. CONCLUSIONS: Bacteremic pneumococcal pneumonia in the setting of AIDS has a survival rate of less than 50 percent with septic shock as the usual mode of death. This is the highest pneumococcal pneumonia mortality rate ever reported in a large subgroup of patients in the antibiotic era. On the other hand, HIV-infected patients without progression to AIDS have an excellent chance for survival. This may be related in part to young age, absence of many underlying diseases, and a better humoral immune system.

Ventilatory support during magnetic resonance imaging.

Ventilatory support during magnetic resonance imaging is difficult because metallic objects on ventilatory support devices can interfere with the imaging field and/or become magnetized and move inside the patient or become flying projectiles. We report the successful MRI examination of an intubated respirator-dependent pediatric patient. Ventilatory support was carried out with a plastic ambu bag, exhalation valve circuit, and tubing.

Prediction equation estimates of creatinine clearance in the intensive care unit.

OBJECTIVE: To assess the accuracy of 4 mathematical equations used to estimate creatinine clearance versus the 24-h creatinine clearance in ICU patients. DESIGN: Prospective study of renal function prediction. SETTING: The general adult ICUs of 3 metropolitan hospitals. PATIENTS: 199 critically ill patients with indwelling foley catheters. INTERVENTION AND MEASUREMENTS: Routine 24 h creatinine clearances were evaluated only in patients whose urine volume recorded by the nurses was within 10% of the laboratory's measured volume. Four mathematical equations utilizing age, sex, body weight, height, and plasma creatinine were used as a comparison. There was no difference in estimated creatinine clearance by 3 published methods when the 24 h creatinine clearance exceeded 100 ml/min. When the 24 h creatinine clearance was less than 100 ml/min, however, one prediction equation adjusted for lean body weight (LBW), was the most accurate. This equation accurately predicted creatinine clearance in the range of 30-100 ml/min and slightly overestimated creatinine clearance at 0-30 ml/min (p < 0.01, ANOVA all groups, p < 0.05 Fisher and Scheffé post-hoc tests) with a mean difference +/- 95% confidence interval of -5 +/- 3.1 ml/min. CONCLUSION: An initial rapid estimate of creatinine clearance in critically ill ICU patients with reduced renal function can be determined by an equation adjusted for LBW.

Relationship between glucose oxidation and FFA concentration in septic cancer-bearing patients.

Glucose oxidation is inhibited in severely ill patients. The present investigation was designed to study the relationship between glucose tissue uptake, glucose oxidation, and FFA concentration in septic cancer-bearing patients. The influence of glucose infusion alone (3.9 mg x kg-1 x min-1), followed by a euglycemic clamp with the same glucose load, on oxidation of glucose, plasma FFA concentration, and lipid oxidation were measured in eight septic cancer-bearing patients. During infusion of 3.9 mg glucose x kg-1 x min-1 glucose tissue uptake was 4.6 +/- 0.3 mg x kg-1 x min-1, glucose oxidation 0.5 +/- 0.2 mg x kg-1 x min-1, FFA concentration 377 +/- 52 mumol x L-1, and lipid oxidation 2.0 +/- 0.2 mumol x kg-1 x min-1. During the euglycemic clamp glucose tissue uptake was 4.4 +/- 0.3 mg x kg-1 x min-1, glucose oxidation rose to 1.8 mg x kg-1 x min-1 (.001 less than P less than .01), FFA concentration dropped to 202 +/- 23 mumol x L-1 (P less than .001), and lipid oxidation to 1.2 +/- 0.2 mumol x kg-1 x min-1 (.001 less than P less than .01). Nonprotein respiratory quotient rose from 0.73 +/- 0.02 to 0.85 +/- 0.02 (.001 less than P less than .01); 11% +/- 5% of the total amount of glucose taken up by the tissues was oxidized during infusion of glucose alone and increased to 42% +/- 6% during the euglycemic glucose clamp. It is concluded that in septic cancer-bearing patients glucose oxidation is inhibited during infusion of 3.9 mg glucose x kg-1 x min-1, even when expressed as percentage of glucose tissue uptake. With insulin, glucose tissue uptake was not influenced, but glucose oxidation expressed as percentage of glucose tissue uptake was normalized.

Human phenol sulfotransferases: chiral substrates and expression in Hep G2 cells.

Enzymatic sulfation of chiral phenolic ethanolamine drugs, e.g. beta-agonists, has been shown to be stereoselective in humans. The reaction appears to be specific for the monoamine (M) form of the phenol sulfotransferases (PSTs). In further studies of the stereochemistry of this reaction, we have found the hepatoblastoma-derived cell line Hep G2 to be an excellent human model. These cells contain the M form PST in quantities exceeding those of human liver by about 4-fold. Thus, sulfate conjugates of the beta-agonist drugs can easily be synthesized for subsequent structural and enzyme kinetic studies. Although less abundant, the phenol (P) form PST as well as dehydroepiandrosterone sulfotransferase are also expressed in the Hep G2 cells.

New-onset generalized seizures in patients with AIDS presenting to an emergency department.

OBJECTIVE: To determine the etiology of new-onset generalized seizures in patients with AIDS presenting to an ED. Patients without HIV infection with a first-time seizure were used as a comparison group. With these data, the current American College of Emergency Physicians (ACEP) guidelines on the workup of new-onset seizures were applied to determine whether they could safely be used in patients with AIDS. METHODS: The authors conducted a retrospective review of all patients with new-onset generalized seizures who presented to an academic medical center hospital ED in New York City over 2 years. A standard ED medical evaluation with history, physical examination, and routine laboratory studies-including at least a panel 7 chemistry, serum magnesium, and complete blood count-was performed. RESULTS: The causes of new-onset seizures in 26 patients with AIDS were idiopathic (8), HIV encephalopathy (8), CNS toxoplasmosis (5), alcohol withdrawal (2), progressive multifocal leukoencephalopathy (2), and CNS lymphoma (1). In 120 patients without HIV infection, idiopathic (43) and alcohol withdrawal (29) were the most common diagnoses. Six patients with AIDS had CNS lesions necessitating immediate admission to the hospital (5 with toxoplasmosis and 1 with lymphoma). Only 2 of 6 had findings on initial ED examination that would have suggested admission under current guidelines written for patients without HIV infection. The 4 patients with no findings were 3 with CNS toxoplasmosis and 1 with CNS lymphoma. CONCLUSION: Four of 26 AIDS patients with immediately treatable CNS lesions could have been sent home for outpatient evaluation of their seizures on the basis of current guidelines for non-HIV-infected patients. However, the updated 1997 ACEP guidelines now include emergent brain neuroimaging studies on patients who have or are suspected of having AIDS. This study helps to strengthen this recommendation. Based on these findings, the authors suggest a neuroimaging study with a lumbar puncture, if indicated, in the ED or inpatient admission workup for all patients with AIDS or suspected AIDS presenting with new-onset generalized seizures.

Emergency department characteristics of male sexual assault.

OBJECTIVE: To characterize the nature, frequency, and treatment of male sexual assault encountered by physicians in an ED. A minor objective compared the lengths of time the victim knew the assailant between males and females to determine whether there were differences between male and female victims. METHODS: Retrospective review over four years of all male patients with a diagnosis of sexual assault presenting to an urban academic ED in New York City. Demographics, types of injury, assailant/victim information, and treatment of the assault were obtained. RESULTS: Twenty-seven male sexual assaults (approximately 12% of all sexual assaults) were documented during this time period. Forcible rectal, oral, or both rectal and oral intercourse occurred 14, 4, and 9 times, respectively. Documented physical trauma occurred in nine of 27 visits, with two admissions for head trauma. Five additional patients complained of rectal pain with no independent objective evidence of trauma. Prophylactic treatment with antibiotics for the prevention of Neisseria gonorrhoeae and Chlamydia trachomatis was offered in 26 of 27 episodes and prophylactic HIV protection was given to only two of 21 eligible patients. Documentation of HIV status and HIV counseling occurred only in ten and five visits, respectively. The male-to-female odds ratios for whether the assailant was unknown, known less than 24 hours, or known more than 24 hours were 0.43 (95% CI = 0.15 to 1.26), 2.48 (95% CI = 0.94 to 6.53), and 0.92 (95% CI = 0.31 to 2.71), respectively. CONCLUSIONS: The percentage of total sexual assaults occurring in males who present to an ED is now more than 10% of all sexual assaults seen in this urban ED. These assaults are associated with a high proportion of patients with documented trauma. Although the treatment of traditional sexually transmitted diseases appears to be covered well, the need for HIV documentation, counseling, and possible HIV prophylaxis should be addressed more aggressively. In comparing the lengths of the relationships between the victim and the assailant, it appears twice as likely that the female victim will not know her assailant compared with the male, and twice as likely that the male victim will know his assailant less than 24 hours compared with the female.

Epinephrine transiently increases amino acid disappearance to lower amino acid levels in humans.

BACKGROUND: Infusion of epinephrine decreases plasma amino acid concentrations. However, the mechanism by which this decrement occurs is not well characterized. METHODS: Epinephrine was infused (40 ng/kg/min) for 2 hours into eight normal healthy adults. The essential amino acid tracers L-[1-(13)C]leucine and L-[phenyl-2H5]phenylalanine were infused before and during the epinephrine infusion and blood samples obtained to determine amino acid rates of appearance and disappearance from the time course of change in amino acid concentration and tracer enrichments. RESULTS: Epinephrine infusion decreased plasma leucine and phenylalanine concentrations over a period of 30 to 90 minutes after the start of the epinephrine infusion. Epinephrine infusion induced an immediate decrement in tracer enrichments. These changes defined sharp increases in both rate of appearance and rate of disappearance. By 30 minutes of epinephrine infusion, the rate of amino acid appearance from proteolysis had returned to baseline, but the rate of amino acid disappearance remained elevated for 90 minutes before returning to baseline. It was the protracted increase in amino acid disappearance that was responsible for the lowering of plasma amino acid concentrations. After this acute response, rates of amino acid appearance and disappearance returned to normal whereas plasma amino acid levels remained suppressed. CONCLUSIONS: Epinephrine transiently affects both rates of amino acid appearance and disappearance, with the net effect being increased in amino acid disappearance. However, epinephrine lowers amino acid concentrations beyond the period that it affects kinetics. These results suggest that the effect of epinephrine on amino acid metabolism is not detrimental and that epinephrine allows amino acid metabolism to proceed normally but at lower concentrations of amino acids.

Intravenous glycerol infusions: effect on free fatty acid metabolism.

The plasma-free fatty acid response to intravenous glycerol infused at 250 and 500 mumol/min was determined in five normal volunteers in the postabsorptive state. There was a drop in free fatty acid concentration in all five subjects (one-way ANOVA, p less than 0.01) after the glycerol infusion with no change in insulin concentration compared to the post-absorptive state. These results suggest that intravenous glycerol infusions decrease free fatty acid concentrations in the post-absorptive state by an insulin-independent mechanism. When pharmacologic nonisotopic glycerol infusions are used to determined lipolytic rate, simultaneous measurement of free fatty acid concentrations should be interpreted with caution.

Insulin sensitivity in septic cancer-bearing patients.

Resistance to insulin's effect on glucose metabolism is a well-documented phenomenon. The magnitude of resistance to insulin's antilipolytic action is usually less than the resistance to insulin's action on glucose metabolism. In sepsis, resistance to the antilipolytic effect of insulin may be more prominent than resistance to insulin's action on glucose metabolism. Therefore, free fatty acid (FFA) turnover, FFA concentration, glucose tissue uptake, and endogenous glucose production were measured in nine septic cancer-bearing patients and six healthy volunteers during a constant glucose load at two different insulin concentrations. During infusion of glucose alone, plasma insulin concentration in patients and control subjects were, respectively 33 +/- 7 mU/L and 23 +/- 4 mU/L. When plasma glucose was clamped at the low normal range these values were, respectively, 85 +/- 17 mU/L and 28 +/- 5 mU/L (p less than 0.05). Glucose tissue uptake and endogenous glucose production were not significantly different in patients and control subjects in both parts of the study. FFA turnover and FFA concentrations were significantly higher in the patients compared with the control subjects (p less than 0.001) in both parts of the study. It is concluded that in septic cancer-bearing patients, resistance to insulin's effect on FFA turnover is more pronounced than resistance to its inhibiting effect on endogenous glucose production and its stimulating effect on glucose tissue uptake.

Glycerol metabolism in humans: validation of 2H- and 13C-labelled tracers.

For a tracer to be valid it must follow the metabolism of the tracee without distortion. Especially when the tracer contains several deuterium substitutions, the tracer can be altered or degraded differently from the metabolite it is to trace or be subject to distorting isotope effects. To determine whether 2H5-glycerol is a valid tracer for following glycerol kinetics, 2H5-glycerol and [2-13C]glycerol tracers were infused simultaneously in six healthy postabsorptive adult subjects. After 90 min of tracer infusion, epinephrine was also infused for 60 min to stimulate lipolysis and increase glycerol flux. Glycerol flux increased from 2.2 +/- 0.3 to 6.7 +/- 0.4 mumol/kg per minute (with the 13C tracer) and from 2.2 +/- 0.3 to 6.7 +/- 0.3 mumol/kg per minute (with the 2H tracer) when epinephrine was infused. There was no significant difference in glycerol flux measured with the 2H tracer compared to the 13C tracer either under basal or a stimulated flux condition. These results indicate that 2H5-glycerol is a valid tracer for measuring glycerol metabolism in humans.

Heparin dosing for percutaneous coronary angioplasty: use of body surface area to improve initial activated clotting time values.

BACKGROUND: Activated clotting time (ACT) values during percutaneous transluminal coronary angioplasty (PTCA) after the initial 10,000 U heparin bolus are often below target values of 350 or 400 s (Hemochron) and have to be supplemented with additional heparin. This study evaluated the initial 10 min post-heparin bolus clotting time value using a body surface area (BSA)-adjusted heparin bolus versus the traditional 10,000 U heparin bolus. HYPOTHESIS: Body surface area adjustment of initial heparin dosing prior to PTCA will be more effective in reaching target ACT values compared with the 10,000 U heparin bolus method. METHODS: Twenty-seven patients receiving the BSA-adjusted heparin bolus were compared with 27 age- and gender-matched controls who had received the traditional heparin bolus. The adjusted heparin bolus formula used was [BSA(m2)/1.3m2] x 10,000 U of heparin. RESULTS: The success rate at reaching the target value of 400 s was 13 of 27 (48.1%) and 2 of 27 (7.4%) for the BSA-guided and 10,000 U heparin-guided groups, respectively (p < 0.01). The success rate at reaching the 350 s target value was 25 of 27 (92.6%) and 6 of 27 (22.2%) for the BSA-guided and 10,000 U heparin-guided groups, respectively (p < 0.01). The 95% confidence intervals for the difference in success between the BSA-guided and 10,000 U heparin-guided groups were 0.19-0.62 and 0.52-0.89 for the 400 s and 350 s ACT targets, respectively. CONCLUSION: Body surface area adjustment of initial heparin dosing is a more effective method of reaching the initial ACT target values of 350 and 400 s compared with the traditional method prior to PTCA. This conclusion applies to the Hemochron ACT device and arterial samples, and adjustments may need to be made for other devices and/or venous samples.

Lowering of plasma glucose concentration in septic cancer-bearing patients: metabolic significance.

Previous work has indicated that 40-50% of glucose intake is oxidized in normal humans with protein-sparing effect. In contrast, the catabolic stressed patient is hyperglycaemic with decreased glucose oxidation and protein wasting. This study evaluated whether the plasma glucose concentration alone would be a reliable indicator of efficient glucose utilization and protein sparing in the critically ill septic cancer patients receiving glucose infusions. Glucose turnover, glucose concentration, nitrogen excretion, oxygen consumption, and glucose oxidation were measured in 8 septic cancer-bearing patients during a glucose infusion of 4.0 mg/kg/min followed by the infusion of insulin with the same glucose load. During glucose infusion without insulin the glucose concentration was 11.8 +/- 1.4 mmol/l, glucose oxidation 10 +/- 5% of glucose tissue uptake, and nitrogen excretion 9.0 +/- 1.3 mg/kg/h. During the euglycaemic clamp the glucose concentration was 3.8 +/- 0.2 mmol/l, glucose oxidation increased to 45 +/- 6% of glucose tissue uptake (p < 0.001), and nitrogen excretion dropped to 6.8 +/- 1.2 mg/kg/h (p < 0.001). The glucose concentration was greater than 10 mmol/l in 4 patients and between 6.9 and 9.3 mmol/l in 4 patients after glucose infusion alone. Despite this difference in initial glucose concentration, normalization of plasma glucose to less than 5 mmol/l with insulin resulted in the same decrease in nitrogen excretion and improvement in glucose oxidation. We conclude that, independent of the initial glucose concentration, maintenance of euglycaemia with insulin appears to be a good indicator of efficient glucose utilization and protein sparing in septic cancer-bearing patients receiving glucose as the primary mode of nutritional support.

Urinary creatinine excretion in the ICU: low excretion does not mean inadequate collection.

BACKGROUND: It has been assumed that a urinary creatinine excretion rate of less than 10 mg/kg per day means an inadequately collected urine sample. OBJECTIVE: To determine the frequency of a urinary creatinine excretion rate of less than 10 mg/kg per day in intensive care unit patients with an adequately collected urine sample. METHOD: In a prospective study of creatinine excretion rates, 24-hour urine samples were evaluated for urinary creatinine in 209 critically ill patients with indwelling Foley catheters. Patients from three adult intensive care units in New York City were divided into two groups. Group 1 patients excreted less than 10 mg/kg per day of urinary creatinine, and group 2 patients excreted at least 10 mg/kg per day. Groups 1 and 2 were first evaluated by dividing the creatinine excretion data by actual body weight. Since actual body weight may overestimate body weight in the critically ill patient, data from groups 1 and 2 were also evaluated using lean body weight. RESULTS: Urinary creatinine excretion was less than 10 mg/kg per day in 36.8% of patients using actual body weight and 29.7% of patients adjusted for lean body weight. The average age of patients in group 1 was 74 +/- 17 years for both actual body weight and lean body weight. The average age of group 2 patients was 60 +/- 19 years for actual body weight and 62 +/- 19 years for lean body weight. There was a significant difference in age between group 1 and group 2 patients for both actual body weight and lean body weight. The proportion of female vs male patients with reduced creatinine excretion was significantly greater, whether the actual body weight or lean body weight adjustment was used. CONCLUSIONS: A urinary creatinine excretion rate of less than 10 mg/kg per day occurs in about one third of critically ill patients, who are more likely to be elderly and female.

Room-temperature thermodilution cardiac output: proximal injectate lumen vs proximal infusion lumen.

OBJECTIVE: To assess the accuracy of room-temperature thermodilution cardiac output measurements from the venous infusion port. DESIGN: Central venous port cardiac output measurements were compared with venous infusion port measurements in 48 right-heart catheters. INTERVENTION: Three 10-mL injections of 5% dextrose in water were made through each port. The order of port injection was random. RESULTS: The cardiac outputs were 5.8 +/- 1.8 L/min from both ports, with no difference between ports (paired t test). CONCLUSION: Room-temperature thermodilution cardiac output determinations from the venous infusion port can be used in place of central venous port cardiac outputs if the central venous port becomes nonfunctional.

Room-temperature thermodilution cardiac output: central venous vs right ventricular port.

OBJECTIVE: To assess the accuracy of room-temperature thermodilution cardiac output measurements from the right ventricular port. In addition, waveform patterns were evaluated to determine the actual location of the right ventricular port. DESIGN: Central venous port cardiac output measurements were compared with right ventricular port cardiac output measurements using the same right-heart catheter. SETTING: The general intensive care unit of Memorial Sloan-Kettering Cancer Center. PATIENTS: Thirty-seven critically ill cancer patients with 38 different right-heart catheters were evaluated. INTERVENTION: Four injections of 10 mL normal saline at room temperature were made through each port; the results of the last three injections were averaged. Cardiac output determinations from both ports were completed in less than 10 minutes. The order of port injection was random. RESULTS: No difference was noted between cardiac output determinations from the two ports in a paired t test. Of 38 right-heart catheters, 17 were in the right ventricle and the other 21 in the right atrium. A comparison of ports in the 17 right ventricle catheters showed no difference with a significant (P < .01; R2 = 0.96) correlation. CONCLUSION: Thermodilution cardiac output measurements using 10 mL normal saline at room temperature can be determined accurately using the right ventricular port if the central venous port becomes nonfunctional.

Left lower quadrant pain of unusual cause.

The differential diagnosis of left lower quadrant abdominal pain in an adult man includes, among others, sigmoid diverticulitis; leaking abdominal aortic aneurysm; renal colic; epididymitis; incarcerated hernia; bowel obstruction; regional enteritis; psoas abscess; and in this rare instance, situs inversus with acute appendicitis. We report a case of situs inversus totalis with left-sided appendicitis and a brief review of the literature. There were several subtle indicators of total situs inversus present that were missed by the physicians and surgeons who initially evaluated the patient prior to surgery. Computed tomography scan with contrast, however, revealed the diagnosis immediately, and treatment was successfully initiated.

Prochlorperazine-induced neuroleptic malignant syndrome.

Neuroleptic malignant syndrome can present in a variety of ways. In a review of the medical literature we could find few well-documented reports of prochlorperazine-induced neuroleptic malignant syndrome. We report such a case with its workup, recognition, and management.