NEUROLEPTIC MALIGNANT SYNDROME OR NMS

This catastrophic reaction to dopamine blocking agents, especially HALDOL, more recently RESPIRADOL, (but all the so-called major tranquilizers have been implicated) can lead to death in up to 50% of cases, especially if not immediately recognized.

The causative agents must be stopped immediately and never started again.

• Three Principal Indicators
  
• Extreme muscle rigidity - one patient had to have a tenosynovotomy of her Achilles tendons (heel cords cut).
• Extreme autonomic instability especially rapid heart rate (over 100), temperatures up to 108 (at which point the brain's proteins denature like the white of an egg and there's no return), sweating, high blood pressure (sometimes over 200 systolic), incontinence. Pulmonary emboli may occur.
• Extreme mental status changes including restlessness, delirium, stupor and coma although patient may be conscious and "locked in." Often mistaken for catatonic schizophrenia (another imaginary "disease of the mind") and treated with even more of the hair of the dog, the anti-psychotic medications and even with electroconvulsive therapy (ECT)!

Laboratory testing can be helpful: the white blood count is elevated and a muscle enzyme, the CPK is usually elevated as well.

Electromyography may show widespread fasciculations (ref: Anderson SA, Weinschenk K: Peripheranl neuropathy as a component of the neuroleptic malignant syndrome: Am J Med 1987 Jan: 82 (1): 169-70) and muscle biopsy is shows diffuse increase in fibres with internal nuclei - see arrows below.

Adams J, Graham D: An Introduction to Neuropathology. Churchill Linvingstone. NY. 1988. page 273.

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