Review Question - QID 107296

A patient with symptoms of fever, mental status change, muscle rigidity, and hypertension, with an elevated CK in the setting of antipsychotic medications, is likely suffering from neuroleptic malignant syndrome (NMS). He should be treated with dantrolene along with cessation of the current antipsychotic.

Neuroleptic malignant syndrome is a rare but potentially fatal side effect of antipsychotic medications. It presents with symptoms such as fever, mental status change, muscle rigidity, autonomic instability, dystonia, and tremor. Labs typically show an elevated CK level along with hyperkalemia and leukocytosis. It is potentially fatal and should be managed aggressively.

Muench et al. discuss the adverse effects of antipsychotic medications. They state that NMS typically occurs more often after high-potency first generation antipsychotics compared to lower potency second generation agents. They recommend immediate treatment of NMS with a muscle relaxant such as dantrolene with or without a dopamine agonist such as bromocriptine along with the discontinuation of the offending agent.

Reulbach et al. compare outcomes of NMS after treatment with (1) dantrolene alone, (2) dantrolene plus bromocriptine or amantadine, (3) other medication, or (4) only supportive care. They note that time to remission was significantly different between all four groups (P<0.01), with time of remission shortest for dantrolene alone compared to all other groups. Furthermore, they also note that patients being treated with depot antipsychotics had a shorter time to complete remission compared to those who were being treated with other formulations.

Incorrect Answers:
Answers 1 and 2: Diazepam and morphine may be helpful for sedation and pain control (respectively) in this patient, but they are not effective in treating NMS.
Answers 4 and 5: Though quetiapine and lamotrigine may be used for mood stabilization purposes after treatment of NMS, they are not useful in this acute setting.