eMedicine Specialties > Psychiatry > Emergency

Neuroleptic Malignant Syndrome: Differential Diagnoses & Workup

Author: Joseph Tonkonogy, MD, PhD, Clinical Professor of Psychiatry and Neurology, University of Massachusetts Medical School; Consulting Staff, Departments of Psychiatry and Neurology, University of Massachusetts Medical Center
Coauthor(s): Darius P Sholevar, MD, Fellow, Cardiovascular Disease, Albert Einstein Medical Center
Contributor Information and Disclosures

Updated: May 7, 2009

Differential Diagnoses

Schizophrenia

Other Problems to Be Considered

Manic-depressive illness
Lethal catatonia
Neuroleptic-induced acute dystonia
Neuroleptic-induced acute akathisia
Neuroleptic-induced tardive dyskinesia
Neuroleptic-induced parkinsonism
Serotonin syndrome
Malignant hyperthermia17
Heat stroke
Central nervous system infections
Status epilepticus
Stroke
Brain trauma
Neoplasms
Acute intermittent porphyria
Tetanus

Workup

Laboratory Studies

  • The rigidity and hyperthermia found in neuroleptic malignant syndrome contribute to muscle damage and necrosis. Elevated blood CK, aminotransferases (aspartate aminotransferase [AST], alanine aminotransferase [ALT]), and lactate dehydrogenase (LDH) reflect damage and necrosis, which can progress quickly to rhabdomyolysis with hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Elevated blood levels of myoglobin and myoglobinuria can be observed and ultimately can lead to renal failure.
  • More general laboratory features include leukocytosis, thrombocytosis, and evidence of dehydration. Cerebrospinal fluid protein might be elevated. Serum iron concentration might be decreased.
  • Investigate other causes for fever based on the clinical scenario.
  • Investigate symptoms and signs of urinary tract, respiratory, and CNS infections.
  • A summary of the laboratory abnormalities associated with neuroleptic malignant syndrome includes the following:
    • Increased LDH
    • Increased CK
    • Increased AST
    • Increased ALT
    • Increased alkaline phosphatase
    • Hyperuricemia
    • Hyperphosphatemia
    • Myoglobinemia
    • Leukocytosis
    • Thrombocytosis
    • Proteinuria
    • Decreased serum iron18
    • Increased cerebrospinal fluid (CSF) protein
    • Hypocalcemia
    • Myoglobinuria

More on Neuroleptic Malignant Syndrome

Overview: Neuroleptic Malignant Syndrome
Differential Diagnoses & Workup: Neuroleptic Malignant Syndrome
Treatment & Medication: Neuroleptic Malignant Syndrome
Follow-up: Neuroleptic Malignant Syndrome
References
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Further Reading

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Keywords

neuroleptic malignant syndrome, antipsychotics, NMS, drug-induced movement disorder, lethal catatonia, neuroleptic-induced acute dystonia, neuroleptic-induced akathisia, neuroleptic-induced parkinsonism, neuroleptic-induced tardive dyskinesia, serotonin syndrome, hyperthermia, rigidity, autonomic dysregulation, 3, 4-methylenedioxymethamphetamine, MDMA, ecstasy, XTC

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Contributor Information and Disclosures

Author

Joseph Tonkonogy, MD, PhD, Clinical Professor of Psychiatry and Neurology, University of Massachusetts Medical School; Consulting Staff, Departments of Psychiatry and Neurology, University of Massachusetts Medical Center
Joseph Tonkonogy, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Neuropsychiatric Association, International Neuropsychological Society, Massachusetts Medical Society, Royal Society of Medicine, Society for Neuroscience, and United Council for Neurologic Subspecialties, Certification Behavioral Neurology and Neuropsychiatry
Disclosure: Nothing to disclose.

Coauthor(s)

Darius P Sholevar, MD, Fellow, Cardiovascular Disease, Albert Einstein Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Alan D Schmetzer, MD, Professor, Vice-Chair for Education, and Director of Residency Training in General and Addiction Psychiatry, Department of Psychiatry, Indiana University School of Medicine
Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American College of Physician Executives, American Medical Association, American Neuropsychiatric Association, American Psychiatric Association, and Association for Convulsive Therapy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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