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Neuroleptic Malignant Syndrome Workup

  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Mar 24, 2016
 

Approach Considerations

No laboratory test result is diagnostic for neuroleptic malignant syndrome (NMS). However, the following laboratory studies may be indicated, to assess severity and complications or rule out other diagnostic possibilities:

  • Complete blood count (CBC)
  • Blood cultures
  • Liver function tests (LFTs)
  • Blood urea nitrogen (BUN) and creatinine levels
  • Calcium and phosphate levels
  • Creatine kinase (CK) level
  • Serum iron level
  • Urine myoglobin level
  • Arterial blood gas (ABG) levels
  • Coagulation studies
  • Serum and urine toxicologic screening (eg, salicylates, cocaine, amphetamines)

General laboratory features in neuroleptic malignant syndrome include leukocytosis, thrombocytosis, and evidence of dehydration. The serum iron concentration might be decreased. The cerebrospinal fluid (CSF) protein concentration might be elevated.[38]

The rigidity and hyperthermia in neuroleptic malignant syndrome contribute to muscle damage and necrosis, which is reflected in elevated blood levels of the following:

  • CK
  • LFTs (aspartate aminotransferase [AST], alanine aminotransferase [ALT])
  • Lactate dehydrogenase (LDH)

Muscle damage and necrosis can progress quickly to rhabdomyolysis with hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Elevated levels of myoglobin can be observed in blood and urine, and may ultimately lead to renal failure.

Assessment of the serum CK level is especially frequently used in psychiatric practice for diagnostic evaluation of rhabdomyolysis in patients with possible neuroleptic malignant syndrome. Other causes of CK elevation may include prescription drugs, alcohol, acute coronary syndrome, and other medical conditions.

Other causes of fever should be investigated, depending on the clinical scenario. This may include urinary tract, respiratory, and central nervous system (CNS) infections. Cultures from various sites may be indicated.

A summary of the laboratory abnormalities that may be found in neuroleptic malignant syndrome includes the following:

  • Increased LDH
  • Increased CK (50-100% of cases)
  • Increased AST and ALT
  • Increased alkaline phosphatase
  • Hyperuricemia
  • Hyperphosphatemia
  • Hyperkalemia
  • Myoglobinemia
  • Leukocytosis (70-98% of cases)
  • Thrombocytosis
  • Proteinuria
  • Decreased serum iron [1]
  • Increased CSF protein
  • Hypocalcemia
  • Myoglobinuria
  • Metabolic acidosis

If thromboembolic phenomenon or disseminated intravascular coagulation (DIC) is suspected, the following coagulation studies may be performed:

  • Platelet count
  • Prothrombin time (PT) and international normalized ratio (INR)
  • Activated partial thromboplastin time (aPTT)

Imaging studies do not yield any diagnostic information for neuroleptic malignant syndrome per se. However, computed tomography (CT) or magnetic resonance imaging of the brain may be performed to rule out other conditions, such as intracranial hemorrhage (ICH), trauma, or structural lesions. Chest radiography is indicated for suspected aspiration pneumonia.

A lumbar puncture (LP) is indicated to rule out meningitis as a cause of fever and altered mental status. No universal agreement exists on the absolute need for a head CT scan before performing an LP in patients without clinical evidence of a structural lesion of the brain; the decision is left to the individual practitioner.

 
 
Contributor Information and Disclosures
Author

Theodore I Benzer, MD, PhD Assistant Professor in Medicine, Harvard Medical School; Director of the ED Observation Unit, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Acknowledgements

Iqbal Ahmed, MBBS, FRCPsych (UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Michael J Burns, MD Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Girish G Deshpande, MD, MBBS, FAAP Associate Professor of Pediatrics, Interim Director and Division Chief of Critical Care Medicine, Department of Pediatrics, University of Illinois College of Medicine at Peoria; Consulting Staff, Division of Critical Care Medicine, Children's Hospital of Illinois at OSF St Francis Medical Center

Girish G Deshpande, MD, MBBS, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Alan D Schmetzer, MD Professor Emeritus, Interim Chairman, Department of Psychiatry, Indiana University School of Medicine; Addiction Psychiatrist, Roudebush VA Medical Center

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.

Darius P Sholevar, MD Fellow, Cardiovascular Disease, Albert Einstein Medical Center

Disclosure: Nothing to disclose.

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph Tonkonogy, MD, PhD Clinical Professor of Psychiatry, University of Massachusetts Medical School; Consulting Staff, Departments of Psychiatry, University of Massachusetts Medical School

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.

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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