Neuroleptic malignant-like syndrome with a slight elevation of creatine-kinase levels and respiratory failure in a patient with Parkinson’s disease
A 68-year-old woman diagnosed with PD for 4 years was admitted to our hospital with chief complaints of hyperthermia and severe muscular rigidity. The patient’s husband reported that she had been on levodopa (600 mg/day), entacapone (300 mg/day), and amantadine (300 mg/day) for almost 2 years. Before her admission, she visited a clinic for progressive impairment of muscular rigidity, where her levodopa was decreased to 125 mg/day. After 2 weeks, the patient’s husband found that his wife was so stiff that she could not even get up on her own. When she was admitted to our hospital, the patient was awake, but developed hyperthermia of 39.7°C, sinus tachycardia of 116 beats/minute, marked muscle rigidity, and aphasia, but her blood pressure was in the normal range (130/80 mmHg). Initial laboratory tests did not change markedly. Blood examination showed a white blood cell count of 8.77 × 109/L (reference range 3.69–9.16 × 109/L), CK level was mildly elevated at 144 U/L (reference range 30–135 U/L). The urine report revealed protein+++ and hematuria+++, suggesting the existence of myoglobinuria. The admission blood culture was negative, so intercurrent infections were ruled out. The immune-related and malignant diseases had also been ruled out, such as tumor markers (α-fetoprotein/carcinoembryonic antigen/Ca125/Ca199/Ca50/squamous cell carcinoma) and autoimmune antibodies (double-stranded deoxyribonucleic acid/antinuclear antibody/extractable nuclear antigen) were within the normal range. By the next day of hospitalization, the diagnosis of probable NMLS secondary to dopamine reduction was made, and her levodopa was increased to 600 mg/day. The next day, her CK level had decreased to the normal range (), but the patient deteriorated with altered levels of blood pressure (160/100 mmHg) and a high fever with a peak temperature above 41°C. On day 3 of her hospital admission, she suddenly developed an acute respiratory failure (45 breaths per minute, oxygen and carbon dioxide partial pressure were 7.55 kPa and 3.79 kPa through nasal catheter, respectively) and disturbance of consciousness (Glasgow Coma Scale score of 4). Her husband agreed to endotracheal intubation and the patient was transferred to the intensive care unit. Cranial computed tomography and magnetic resonance imaging showed atrophic changes and small focal ischemia. Finally, the patient died of lung infection and heart failure 10 days later.