Typical Neuroleptic Malignant Syndrome Presented in Patient on Maintenance Quetiapine
A 46-year-old male patient was brought to Emergency Department of Tertiary Care Centre at Bhavnagar, with, generalized stiffness, fever, generalized tremulousness mutism, perspiration, inability to swallow, intermittent tongue protrusion, sialorrhea, restlessness and insomnia for the last 3 days. Patient was seen by emergency team and was hospitalized in critical care unit. He was diagnosed with schizoaffective disorder of 11 year duration. He was under regular treatment of quetiapine 200 mg/day, divalproex sodium 500 mg/day and lorazepam 4 mg in two divided doses/day since 2006, confirmed by relatives and clinical case records. There was no past history suggestive of similar symptoms, medical disorder or substance use. The paternal uncle was having symptoms of self-talking, abusive, poor self-hygiene, roaming on roads who died at the age of 50 years.\nOn examination, patient was confused, not oriented to time and place. His temperature was 102°F, blood pressure 150/90 mm of Hg, heart rate 104/min, respiratory rate 20/min. He had generalized tremors, cog wheel rigidity in all extremities and orofacial dystonias. The pupils were normal size and reactive to light. Planters were flexor both sides. He was agitated and was pulling intravenous (IV) lines.\nClinically, NMS was suspected. Other differential diagnoses such us meningitis, encephalitis, substance/overdose or withdrawal, metabolic disturbances, seizure, heat stroke were ruled out. Serotonin syndrome was ruled out because of presence of severe rigidity, absence of hyperreflexia, clonus, diarrhea, in coordination and no use of serotonergic reuptake inhibitors. Lethal catatonia was ruled out because patient did not have initial psychotic symptoms. Blood and urine and cerebrospinal fluid (CSF) samples were sent for examination and culture. A head computed tomography scan, chest X-ray and urine analysis and CSF analysis were unremarkable. The physical and laboratory parameters are shown in .\nPatient was admitted in intensive care unit and nasogastric tube and urine catheter was inserted. Quetiapine and divalproex were discontinued. Patient was given 6000 ml/day including dextrose and saline for hydration. Cold water sponging was done regularly to control hyperthermia. Bromocriptine 10 mg in four divided doses through nasogastric tube and intramuscular lorazepam 8 mg/day in two divided doses was started. There was hypernatremia (151 mEq/L) on day 1, which was corrected with successful fluid resuscitation. Vitals, electrocardiogram and urine output were monitored daily. As shown in clinical condition improved on day 3 and patient was able to take oral fluids. The patient was clinically stable and was ambulatory on day 5. There was reemergence of psychotic symptoms such as delusion of jealousy, auditory hallucinations, increased talkativeness and psychomotor activity on the 10th day. Clozapine 25 mg in divided was started with divalproex 500 mg/day. Dose was increased and patient was discharged on the 22nd day with 150 mg/day of clozapine and divalproex 1000 mg/day. Patient significantly improved on discharge and was advised for regular follow-up. Patient well- maintained with the same treatment on follow-up.