Summary: Neuroleptic Malignant Syndrome (NMS) is a state, which commonly presents with autonomic changes like fever exceeding 40 degrees Celsius, muscle rigidity, changes in mental status, tachypnea, and şuctuations in blood pressure. It occurs mostly due to classical antipsychotic drugs with high potency. However, atypical antipsychotic drugs, such as şuoxetine, reserpine and phenothiazine-like antiemetics, can also cause NMS. We present a case of a 38 year-old patient with chronic schizophrenia, who developed NMS after ingestion of the intramuscular form of zuclopenthixol acetate 50 mg/ml twice, two days apart.
Case: A 38 year-old, single, male patient with a diagnosis of chronic schizophrenia for 18 years. While being followed up with clozapine 300 mg/d, amisulpride 200 mg/d for the last 6 months, upon oral administration of zuclopenthixol acetate 50 mg/ml (im) twice, two days apart, by his family for an acute psychotic şare, he presented to the emergency room with sweating, progressive dysphagia, refusal of food intake, hypersalivation, slowing of speech, dysuria, and muscle cramps. On examination, his body temperature was 39.3 degrees Celsius, heart rate was 110 bpm, blood pressure was 120/70 mm-Hg, and the patient was tachypneic (32/min). There were no pathological findings apart from urinary incontinence. On laboratory work-up: WBC=12700/mm3, CPK=3226 U/l, urea=74 mg/dl, creatinine=1.4 mg/dl, Fe=19 U/dl. On follow up, a mild to moderate increase in leukocytosis was seen. For hydration, 2000 cc IV şuid was given as a replacement with regards to his urinary output. All antipsychotic drugs were stopped. He was put on lorazepam 1 mg/dl because of agitation. On follow up, his leukocyte count went back to normal, CPK level was down from 3226 to 102 consecutively. Urea and creatinine levels were 20 mg/dl and 1.4 mg/dl, respectively. His oral intake returned to normal in 5 days; şuid replacement was continued for 3 more days. His rigidity was still present but to a lesser extent and after 10 days the patient was discharged with clinical recovery.
Conclusion: NMS is often seen within 10 days following antipsychotic use; however, regardless of dose and duration of usage, it can be seen at any stage of therapy. There are no cases reported in the literature like ours on oral ingestion of the intramuscular form of an antipsychotic drug. We believe that as the number of case reports on NMS increase, this issue will be better understood.