CHEST Guidelines-A-Woman-in-Her-60s-With-Fever-and-Altered-Mental-S

A-Woman-in-Her-60s-With-Fever-and-Altered-Mental-S

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The presented case involves a woman in her 60s with a history of hepatitis C with cirrhosis and major depressive disorder with psychotic features, admitted to a psychiatric unit for suicidal ideation. Initially treated with sertraline and paliperidone, her medication was switched to risperidone and later olanzapine. This led to worsening mental status, catatonia, fever, and tachycardia, prompting her transfer to the ICU. Initial treatment with benzodiazepines and lactulose did not improve her condition.<br /><br />Upon examination, her vital signs indicated a fever, high pulse, and normal oxygen saturation on assisted breathing. She was unresponsive to commands, her pupils were sluggishly reactive, her sclera were icteric, and she exhibited generalized rigidity without clonus. Laboratory tests showed mildly low hemoglobin, low bicarbonate and albumin levels, and high serum ammonia. A cerebrospinal fluid analysis revealed a high red blood cell count, with slightly elevated white blood cells and proteins. No infections were found through extensive microbiological studies, and her brain MRI and EEG only indicated encephalopathy.<br /><br />Based on these assessments, the diagnosis was Neuroleptic Malignant Syndrome (NMS), a rare but potentially lethal reaction to dopamine antagonist medication, particularly antipsychotics. NMS is marked by altered mental status, high fever, rigidity, and autonomic instability. NMS occurs in approximately 1 in 10,000 patients on antipsychotics, though underrecognition is common. The condition mirrors serotonin syndrome in some symptoms but differs in the absence of hyperreflexia or clonus. <br /><br />Treatment involves cessation of the causative medication, supportive care, and, if needed, specific interventions like dantrolene or dopaminergic agents. The patient, upon discontinuation of olanzapine, showed improvement within four days, leading to her successful transfer back for psychiatric care evaluation. This case underscores the importance of recognizing NMS and differentiating it from other syndromes in ICU patients with similar presentations.

Keywords

Neuroleptic Malignant Syndrome

antipsychotics

dopamine antagonist

psychotic features

suicidal ideation

catatonia

tachycardia

serum ammonia

encephalopathy

dantrolene