Summary
Objective
To report a case of neuroleptic nalignant syndrome (NMS) in a young woman who survived the acute stage that gradually resolved after 3 months. Afterward she developed a chronic motor disability that was resistant to pharmacological treatment.
Case summary
Mrs C.A. is 30-year-old Caucasian woman with mental disability and bipolar disorder type I. In October 2013, she presented with very severe behavioural abnormalities and was treated with intensification of therapy with quetiapine 300 mg TID, haloperidol 4 mg TID, paliperidone 6 mg OD, and fluphenazine decanoate 25 mg i.m. once every 21 days, clonazepam 1 mg OD and lorazepam 2.5 mg OD. In December 2013 extrapyramidal effects developed and hospital admission was necessary. Neuroleptic therapy was immediately stopped. After a few days, fever appeared with consciousness disorders and high levels of creatine kinase. Laboratory tests and imaging studies with negative results were performed. A diagnosis of NMS was made and she received supportive and specific therapy with dantrolene, diazepam, baclofen, rotigotine and L-Dopa. After 3 months, Mrs. C.A. survived NMS but she showed chronic rigidity and mutism. She was transferred to an intensive neurorehabilitation centre.
Discussion
The peculiarity of this case is pre-existing central nervous system (CNS) abnormality and atypical symptoms of NMS at presentation. Her mental disability, the use of polypharmacy and longacting drug likely contributed to the long duration of NMS and its sequelae.
Conclusion
In a patient with extrapyramidal symptoms associated with fever and pre-existing CNS abnormalities and mental disability, particular attention must be given to the use of polypharmacy.