Neuroleptic Malignant Syndrome

Roy Perlis

A. Central features

1. Delirium

2. Rigidity (“lead pipe”)

3. Fever

4. Autonomic instability (tachycardia, diaphoresis, labile BP)

B. Laboratory values (though primarily a clinical diagnosis!)

1. Elevated CPK (MM fraction)

2. Elevated WBC (not always)

C. Risk factors

1. Most often seen with typical neuroleptics.

2. Nonetheless, also reported with atypicals including clozapine.

3. Lithium may increase risk.

D. Differential diagnosis

1. Catatonia (should not be febrile)

2. Delirium (diaphoretic in NMS, dry skin in anticholinergic delirium)

3. Severe parkinsonism (should not have delta MS unless infxn)

E. Treatment

1. Discontinue neuroleptic

2. Pharmacologic options

· dantrolene or bromocriptine

· benzodiazepines

3. Supportive management

· hydration

· antipyretics

· monitor vitals, cardiac rhythm

· follow for rhabdomyolysis, renal failure, arrhythmias, hypoTN

source: Hyman SE and Tesar GE (1994) Manual of Psychiatric Emergencies. Little, Brown.