Expanding the Catatonia Tent: Recognizing Electroconvulsive Therapy Responsive Syndromes.

ABSTRACT: Catatonia is a motor and mood disorder of behavior increasingly recognized in systemic medically ill. Neuroleptic malignant syndrome, delirious mania, self injurious behaviors in autism, and limbic encephalitis are conditions in which ECT-responsive catatonia is increasingly recognized and effectively treated.

Catatonia revived: a unique syndrome updated.

Catatonia was buried within the confines of schizophrenia for over a century- deterring study, appropriate diagnosis and treatment for many years. With revised changes in the classification of this distinct neuropsychiatric syndrome, it is becoming more recognized clinically and in ongoing research. Catatonia occurs among various psychiatric, metabolic or neurologic conditions. It may present in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy usually produces dramatic and rapid response, although systematic, randomized trials are lacking. The role of antipsychotic agents in treatment is controversial as they may worsen the syndrome. An important unresolved clinical question is the diagnosis and treatment of catatonia in the setting of delirium.

Neuroleptic malignant syndrome as a presenting feature of subacute sclerosing panencephalitis.

Subacute sclerosing panencephalitis (SSPE) is a slowly progressive degenerative disorder caused by measles virus. It is characterised by typical clinical and electrophysiological features in the form of slow myoclonic jerks, with progressive cognitive impairment, visual symptoms, and periodic complexes on EEG, with raised titres of anti-measles antibodies in CSF and serum. Atypical presentations of SSPE have been reported including brainstem involvement, ADEM-like presentation, acute encephalitis, and cerebellar ataxia. Presentation with predominant extrapyramidal features is uncommon. We describe a case of SSPE presenting with extensive rigidity with highly elevated CPK values, mimicking neuroleptic malignant syndrome (NMS) which was most probably due to central dopaminergic blockade induced by the disease process. To our knowledge, this is the first case of SSPE presenting with a NMS-like syndrome.

Rituximab-Treated Pemphigus Foliaceus in a Schizophrenic Patient: A Challenging Exercise in Diagnosis, Management, and Follow-Up.

Dermatology was consulted in the care of a 58-year-old man with a history of paranoid schizophrenia, neuroleptic malignant syndrome, a positive purified protein derivative test, and a lack of bathing for approximately 4 years who had been admitted to the hospital because of thick, crusted lesions over an increasing portion of his body. Admitted involuntarily, he was disinterested in the history, physical examination, and diagnostic testing. Comorbid schizophrenia presented a unique challenge because he was unable to participate in his care effectively. His story was told through caregivers. Although mostly compliant, the patient was reserved and indifferent, and had little to add even with direct questions.

Neuroleptic Malignant Syndrome: Complications, Outcomes, and Mortality.

OBJECTIVE: Our study objective was to identify real-world rates of complications, mortality, and outcomes in patients with neuroleptic malignant syndrome (NMS) over the last decade in the United States. METHODS: A total of 1346 patients were obtained from the nationwide inpatient sample for the years 2002-2011. Common complications known to be associated with NMS were identified. Multivariable regression analyses were used to identify predictors of mortality. RESULTS: The most prevalent complication was rhabdomyolysis (30.1%). Other common complications were acute respiratory failure (16.1%), acute kidney injury (17.7%), sepsis (6.2%), and other systemic infections. Unadjusted mortality rate was 5.6%. Older age, acute respiratory failure, acute kidney injury, sepsis, and comorbid congestive heart failure were significant predictors of mortality. Acute respiratory failure was the strongest independent mortality predictor (p < 0.001). CONCLUSION: In our large sample population-based study on NMS, we were able to identify the rates of several preselected complications and the mortality. The identification of independent mortality predictors in this study can guide physicians in the management and prognostication of this rare syndrome.

Hyperosmolar hyperglycemic state secondary to neuroleptic malignant syndrome.

Neuroleptic malignant syndrome (NMS) is often considered to be a precipitating factor for diabetic coma, such as a hyperosmolar hyperglycemic state (HHS). The combination of NMS and a systemic illness such as HHS can be difficult to diagnose because NMS may mask the coexisting condition. Although this coexistence is rare, it may be fatal if not detected early. We report a case of HHS in a 47-year-old male patient that developed after the distinguishing features of NMS had subsided. After the diagnosis of HHS, his recovery was a result of intravenous administration of soluble human insulin and fluid supplementation. Physicians caring for patients with diabetes who are also treated with neuroleptic agents should be aware that NMS may precipitate the development of secondary hyperglycemia despite a history of well-controlled blood glucose levels.

Electroconvulsive in a Schizophrenic Patient With Neuroleptic Malignant Syndrome and Rhabdomyolysis.

We present the case of a middle-aged man with a chronic history of schizoaffective disorder, depressed type, stable on a second-generation antipsychotic. Psychotic symptoms recurred contingent to medication noncompliance necessitating hospitalization. Treatment was complicated by the development of neuroleptic malignant syndrome (NMS). In addition, subsequent medication rechallenges failed because of recurrent rhabdomyolysis and atypical NMS. Electroconvulsive therapy (ECT) treatment was initiated, affording remission of psychotic symptoms and nonrecurrence of NMS and rhabdomyolysis. Our experience confirmed the efficacy of ECT treatment in providing symptom relief of psychosis complicated by recurrent episodes of NMS and atypical NMS. Likewise, it illustrated the efficacy of ECT treatment for rhabdomyolysis.

[Neuroleptic malignant syndrome : Rare cause of fever of unknown origin]. / Malignes neuroleptisches Syndrom : Seltene Ursache für Fieber unklarer Genese.

Neuroleptic malignant syndrome (NMS) is a possible cause of fever of unknown origin (FUO) and is a potentially fatal adverse effect of various drugs, especially of neuroleptics. First generation antipsychotics, such as received by the patient described in this article, are more likely to cause NMS than second generation antipsychotics. The key symptoms are the development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication. Malignant catatonia (MC) is an important differential diagnosis of NMS. While neuroleptics can trigger NMS and must be immediately discontinued if NMS occurs, neuroleptic therapy represents the first line treatment for MC. This article describes the case of a patient with schizoaffective disorder where initially the diagnosis of NMS was not clear. Eventually, fever and a markedly elevated serum creatine kinase (CK) led to the correct diagnosis and the appropriate therapy with dantrolene, bromocriptine and amantadine. Furthermore, a thorough review of the currently available literature on NMS is provided.

Improving Psychiatric Nurses' Detection of Neuroleptic Malignant Syndrome.

Patients with psychiatric disorders receive nursing care in psychiatric units, medical units and long-term care facilities. Like other patients, their well-being is reliant upon knowledgeable caregivers. The pharmacological interventions that patients are dependent on can have catastrophic effects; of particular concern is Neuroleptic Malignant Syndrome (NMS). This article affords a succinct review of the literature related to NMS and provides suggestions for psychiatric nurse educators to facilitate early recognition, thereby reducing mortality and morbidity. Emphasis is placed on educational tools to help reduce under-detection. A case study illustrates how under-detection can lead to a near fatal outcome.

Reversible abnormality of the splenium in a bipolar patient with neuroleptic malignant syndrome.

OBJECTIVE: To report reversible abnormality of the splenium in a bipolar patient with neuroleptic malignant syndrome (NMS). METHODS: We studied a 23-year-old male who received oral and parenteral neuroleptics, atypical antipsychotic agents, and mood stabilizers, as well as a course of six electroconvulsive therapy treatments, for an episode of mania. He improved. Five days after discharge on maintenance atypical antipsychotic agents and mood stabilizers, he returned with symptoms suggestive of NMS. Laboratory investigations revealed leucopenia, thrombocytopenia, and elevated creatine phosphokinase levels. Brain magnetic resonance imaging showed swelling of the splenium with centrally restricted diffusion; there was no other abnormality. He was defensively treated with antimicrobials, methylprednisolone, and bromocriptine. RESULTS: Clinical recovery was complete after nine days, and the splenium lesion resolved after four further days; there were no neuropsychiatric sequelae. Nine months later, the patient remains well on maintenance lithium therapy. CONCLUSIONS: This is the first report of an isolated splenial lesion reversing within days of resolution of NMS. The outcome supports the recent literature which suggests that an isolated splenial lesion does not need investigation, and that prognosis depends on the underlying disorder, and not on the presence or absence of the splenial lesion.

[Coronary artery spasm induced by neuroleptic malignant syndrome during off-pump coronary artery bypass grafting; report of a case].

A 61-year-old woman with a left main lesion and coronary spastic angina was scheduled for off-pump coronary artery bypass grafting (OPCAB). She had been orally receiving selective serotonin reuptake inhibitor( SSRI) for the treatment of depression. OPCAB to left anterior discending artery( LAD) and left circumflex branch (LCX) was performed using the bilateral internal thoracic arteries assisted by intra-aortic balloon pumping. When the sternotomy was going to be closed, ST elevation of electrocardiogram (ECG) occurred and was followed by complete atrio-ventricular (AV) block. After returning to intensive care unit (ICU), the patient showed rapid elevation of the body temperature, excessive sweating, progressive metabolic acidosis, and abnormal high levels in white blood cell count and creatine phosphokinase. On suspicion of neuroleptic malignant syndrome(NMS) onset, dantrolene sodium hydrate was administered, resulting in marked improvement of the symptoms. We have concluded that this case was an NMS combined with coronary artery spasm during OPCAB treated successfully with dantrolene sodium hydrate.

Transient Fever Response After ECT in a Patient with Catatonic Schizophrenia: A Case Report. / Katatonik Sizofreni Hastasinda EKT Sonrasi Ortaya Çikan Geçici Ates Yaniti: Olgu Sunumu.

Electroconvulsive therapy (ECT) is an effective and safe treatment method for many psychiatric disorders. In general medical practice, ECT may cause side effects as most other treatment methods do. Headache, myalgia, nausea, vomiting, confusion, anterograde amnesia are common side effects of electroconvulsive therapy. Fever; in addition to general medical conditions such as infection, malignancy, connective tissue diseases, drug treatments, malignant hyperthermia, convulsions, it can also occur due to conditions such as neuroleptic malignant syndrome (NMS), serotonin syndrome, catatonia, malignant catatonia, which are frequently encountered in psychiatry clinics. In the literature, transient fever response due to electroconvulsive therapy application have been described, albeit rarely. Although there are many proposed mechanisms for the emergence of a fever response, regardless of its cause, it is still not understood why some fever responses occur. In this article, we present the differential diagnosis of the fever response, possible causes, and the mechanisms that may reveal the secondary fever response to electroconvulsive therapy in a case with a diagnosis of catatonic schizophrenia, who developed a fever response during electroconvulsive therapy sessions and no fever response was observed at times other than electroconvulsive therapy sessions. In this case, postictal benign fever response associated with electroconvulsive therapy was considered after excluding other medical conditions that may cause a fever response after electroconvulsive therapy. Keywords: ECT, Fever, Catatonia, NMS.

Retrospective chart review of catatonia in child and adolescent psychiatric patients.

OBJECTIVE: Identify the frequency of catatonia among at-risk children and adolescents receiving psychiatric treatment. METHOD: Subjects were children and adolescents (<18 years), who had received psychiatric treatment at a University Hospital during 2004-2009, and were diagnosed with disorders with known risk for catatonia or displayed symptoms suggestive of catatonia. Approval was obtained from the Investigational Review Board (IRB). The first 101 (n = 101) subjects were selected among 570 subjects identified by psychiatric diagnoses: any pervasive developmental disorder, psychosis-NOS (Not Otherwise Specified), intermittent explosive disorder, mental retardation, catatonia and neuroleptic malignant syndrome. Subjects met study-defined criteria for catatonia, if they had three or more of the following symptoms: unexplained agitation/excitement, disturbed or unusual movements, reduced movements, repetitive or stereotyped movements, or reduced or loss of speech. RESULTS: Eighteen (17.8%) subjects, among a group suspected to be at a higher risk for catatonia, met the study-defined criteria for this syndrome. However, only two subjects had been diagnosed by their treatment providers. Higher rates of intellectual disability and aggression were found among the group that met study-criteria. CONCLUSION: We concluded that catatonia is under recognized and undertreated among children and adolescents receiving psychiatric treatment.

Coexistence of neuroleptic malignant syndrome and a hyperosmolar hyperglycemic state.

Neuroleptic malignant syndrome (NMS) is a rare idiosyncratic disorder characterized by muscle rigidity, hyperthermia, autonomic dysfunction, and altered consciousness. Although the incidence of NMS is low, it may be fatal if early recognition is delayed. There are a variety of precipitating factors for NMS including systemic illness and dehydration. The combination of NMS with systemic illness can be difficult to diagnose because the systemic illness may mask the coexistence of NMS. We report a patient with hyperosmolar hyperglycemic state with coexistent NMS to remind physicians that hyperosmolar hyperglycemic state may precipitate the development of NMS in patients receiving neuroleptics.

Case Report: A Patient With Neuroleptic Malignant Syndrome, Water Intoxication and Hyponatremia Associated With Severe Cerebral Edema and Coma.

Background: Water intoxication is typically caused by primary or psychogenic polydipsia that potentially may lead to fatal disturbance in brain functions. Neuroleptic malignant syndrome (NMS) is a serious complication induced by administration of antipsychotics and other psychotropic drugs. The combination of inappropriate secretion of antidiuretic hormone (SIDAH), NMS and rhabdomyolysis have been rarely reported. Our patient also developed severe water intoxication. Case presentation: Herein we report a comatose case of NMS complicated with water intoxication, syndrome of SIADH and rhabdomyolysis. This patient had severe cerebral edema and hyponatremia that were improved rapidly by the correction of hyponatremia within a couple of days. Conclusions: Malignant neuroleptic syndrome water intoxication, SIADH and rhabdomyolysis can occur simultaneously. Comatose conditions induced by cerebral edema and hyponatremia can be successfully treated by meticulous fluid management and the correction of hyponatremia.

Neuroleptic malignant syndrome in a postoperative patient: A case report.

Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis. A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity. Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms. The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.

Neuroleptic Malignant Syndrome: A Potential Etiology of Multisystem Organ Failure in a Burn Patient.

Neuroleptic malignant syndrome (NMS) is described in the medical literature but rarely seen among acutely ill trauma patients. A 44-year-old man with burns to the hands and back after a chemical explosion was transported to an outside facility where he received treatment for presumed acute coronary syndrome after developing ventricular tachycardia and elevated serum troponins after the exposure. His cardiac catheterization was unremarkable, but an echocardiogram revealed severe cardiomyopathy, and he was also in multisystem organ failure. He was transferred to our facility after hospital day 2 for treatment of his multisystem organ failure and 2% total body surface area burns. His laboratory results were remarkable for a creatine kinase of >100 000 units/L, and he required 14 g of intravenous calcium. Upon further investigation, the patient reported taking ziprasidone for his bipolar disorder, and he had a core temperature of 103.5 °F on his initial presentation to the outside facility. As he convalesced, the unifying diagnosis was NMS. NMS is a side effect of antipsychotic therapy and is manifested by hyperpyrexia, rigidity, autonomic instability, and altered consciousness. An elevated creatine kinase >100 000 units/L is almost pathognomonic for NMS. Patients can also present with leukocytosis, organ failure, and electrolyte disturbances including hypocalcemia. We hypothesized that dehydration, the warm environmental conditions at our patient's job, and immense stress resulting in a catecholamine surge following his trauma were inciting triggers to this event. This case highlights the importance of considering alternate diagnoses in patients whose clinical presentation does not fit the most "obvious cause."

Long-term management issues in restless legs syndrome.

Restless legs syndrome is a neurologic movement and sleep disorder with lifelong symptoms causing considerable morbidity. Several short-term and some long-term open-label and double-blind clinical trials have demonstrated the efficacy and safety of dopaminergic treatment in restless legs syndrome. Long-term treatment, however, is associated with the emergence of vexing long-term side effects that pose a challenge for physicians. These long-term complications can be broadly categorized as disease-related (impact on sleep and acute exacerbation of restless legs syndrome symptoms), and medication issues (augmentation, sleep attacks, impulse control disorders, addiction and dependence, site reaction, occasionally sleep apnea, fibrotic complications, and weight gain).