Intensive electroconvulsive therapy in drug resistant neuroleptic malignant syndrome - case report.

Neuroleptic malignant syndrome (NMS; ICD-10 code: G21.0) is a rare, although potentially life-threatening adverse reaction to antipsychotic drugs and other dopamine-modulating agents. Symptoms of NMS include: severe muscle rigidity, fever, autonomic instability, mental status changes and laboratory abnormallities (elevated serum levels of creatinine kinase, aldolase, transaminases, lactic acid dehydrogenase, decreased serum iron concentrations, metabolic acidosis and leukocytosis) (Strawn et al. 2007). Almost all antipsychotics have been associated with NMS, both typical (Caroff & Mann 1993) and atypical (Caroff et al. 2000). Central dopamine hypoactivity induced by withdrawal of dopaminergic agents or antipsychotics blocking dopamine receptors plays a crucial role in triggering NMS (Mann et al. 2000, Živković et al. 2010). Almost all cases of NMS develop within 30 days after initiation of antipsychotic treatment (Caroff & Mann 1988). Differential diagnosis should include neuroinfections, agitated delirium, malignant catatonia, status epilepticus, extrapyramidal side effects, malignnant hyperthermia, serotonin syndrome and others (Strawn et al. 2007). Several rating scales were developed to track the clinical course of NMS. FrancisYacoub NMS Rating Scale is a 23-item scale evaluating motor, behavioral, autonomic and laboratory domains of NMS (Yacoub et al. 2004). Usually NMS is self-limiting after antipsychotics are discontinued with average duration of recovery in the range of 7-10 days (Caroff & Mann 1988). Treatment of NMS includes cessation of an antipsychotic, benzodiazepines, dopaminergic agents (bromocriptine, amantadine) and dantrolene sodium (Strawn et al. 2007). Volume resuscitation, correcting electrolyte abnormallities, cooling measures and correcting risk factors are paramount. Electroconvulsive therapy (ECT) is effective in many cases of NMS, even if drug therapy has failed (Trollor & Sachdev 1999). A systemic review of literature data indicates that antipsychotic use following NMS may be re-initiated, however a likelihood of developing another NMS is up to 30% (Pope et al. 1991), even for clozapine (Manu et al. 2011). A case of severe drug resistant severe neuroleptic malignant syndrome induced by clozapine and haloperidol that successfully resolved after intensive electroconvulsive therapy is presented below. The patient gave free, informed consent for the publication of his case.