Letters to the Editor
A Curious Case of Neuroleptic Malignant Syndrome
Dear Editor:
The patient, a white male, aged 51 years and suffering from schizophrenia, had recently been switched from thioridazine to risperidone. His illness began in the early 1970s and was initially characterized by deteriorating psychosocial level of functioning. He demonstrated poor concentration, poor impulse control, and persecutory delusions. A movement disorder was present, characterized by choreiform movements of his limbs and facial grimaces, which eventually subsided. At the time, these were felt to be abnormal movements, though they were not considered tardive dyskinesia. At that time, he was also switched from haloperidol to thioridazine. The patient had been maintained on thioridazine and was doing extremely well until about 11 days before coming to medical attention, when he was switched from thioridazine to risperidone. The patient claimed it was because of a “slow heart.” His QTc interval was prolonged with thioridazine; hence the switch was made.
Approximately 6 days after the change in medication, the patient’s mental state began to deteriorate. He began asking questions such as, “why do children cry?” Community psychiatric nurses also noted the patient had become rather sexually inappropriate. On admission to hospital, he had marked cognitive decline, poor concentration, and poor memory. He was perplexed and not oriented in time or place. It was becoming extremely difficult to understand the patient and follow his thoughts—he had become illogical. On admission to hospital, his vital signs were stable, and while in hospital, he had a grand mal seizure. He was then transferred to the intensive care unit (ICU). There, it was noted that the patient had a right arm abnormality, which was later discovered to be a humeral neck fracture. When the patient was seen, there was an elevation in the creatinine kinase level, and it was felt that this was evidence of neuroleptic malignant syndrome. He did not develop a fever (that is, a temperature greater than 38.5 ºC) at any point. He was extremely rigid. Initially, the ICU staff felt there was a possibility of encephalitis. A lumbar puncture was done, which was normal.
It was felt that the patient had a variant of neuroleptic malignant syndrome. He was extremely rigid, though not febrile. Risperidone was discontinued, and he was placed on clozapine. Since that time, he has been functioning well in the community.
Harminder Anand, MD, FRCPC
D Spaner, MD, FRCPC
Edmonton, Alberta
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