Olanzepine-induced neuroleptic malignant syndrome in a case of multiple sclerosis
A 25-year-old man, with a background history of multiple sclerosis in remission for two years came to the Accident and Emergency department with weakness in his right arm and leg for 6 h. He also had ataxia. There was no focal/urinary incontinence or visual disturbances. He was started on methyprednisolone 1 g intravenously. On the third day, the patient had jerky movements and shivering. Axillary temperature was recorded at 38.6°C. He also had dysarthria, past pointing and blurring of vision and nystagmus. He was very anxious, tearful, and apprehensive; diagnosis of psychosis was made, and the patient was started on olanzepine 2.5 mg BD. He also had a lumbar puncture done for nystagmus and ataxia. On the sixth day patient was tachypneic and had tachycardia. He was very drowsy. Temperature recorded in the axilla was 45°C. Leucocyte count was 22,000 cells/mm3. Creatinine kinase (CK) levels were 15,650 u/L [normal 30-190 u/L], serum alanine aminotransferase was 146 [normal 15-45] and alkaline phosphatase was 660 [normal < 300]. Patient was tachycardic, diaphoretic with incontinence and altered consciousness. Patient was intubated and electively ventilated. His CK levels continued to rise. His urine output decreased with increasing levels of creatinine and urea. Hemodialysis was initiated due to oliguria and rising renal parameters. The temperature was measured continuously via a rectal probe. At all times temperature was above 40°C. A diagnosis of Neuroleptic malignant hyperthermia was made. Arterial lines and a central line were inserted. Patient was well hydrated. Active cooling measures were initiated. Bloods were closely monitored for evidence of Disseminated intravascular coagulation (DIC) and electrolyte imbalance. An antipyretic was started. Patient was started on bromocryptine 5 mg NG TDS, Dantrolene 200 mg IV QDS, baclofen 10 mg TDS and clonidine 100 micrograms BD. The symptoms of NMS started resolving after nearly 4 h. The tachycardia and muscle rigidity had significantly reduced by the first day. Patient made a complete recovery in two days. MRI of the brain revealed extensive plaques in brainstem and swelling of the brain. A diagnosis of multiple sclerosis with superimposed acute demyelinating encephalomyelitis was made. The patient was extubated three days.