Pediatric Neuroleptic Malignant Syndrome Clinical Presentation

  • Author: Mary C Mancini, MD, PhD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Nov 21, 2011
 

History

Symptoms of neuroleptic malignant syndrome include the following:

  • Neuroleptics either recently started or dosage recently increased
  • Neuroleptic malignant syndrome usually evolves over 24-72 hours.
  • Hyperthermia (temperature >38°C)
  • Altered mental status
  • Rigidity and other extrapyramidal syndrome (EPS) symptoms
  • Autonomic dysfunction (eg, urinary incontinence, diaphoresis, sialorrhea)
  • Dyspnea, dysphagia
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Physical

  • General examination findings
    • Hyperthermia
    • Tachycardia
    • Tachypnea, respiratory distress (31% of cases)
    • Hypotension or hypertension
    • Hypoxemia (low pulse oximeter reading)
    • Dehydration (secondary to hyperpyrexia and inadequate oral intake)
  • Neuromuscular examination findings
    • Altered mental status (status ranging from drowsiness and confusion to coma)
    • Muscular rigidity (usually lead-pipe type)
    • Autonomic dysfunction (eg, dysrhythmias, urinary incontinence, diaphoresis, sialorrhea, tachycardia, hypotension, hypertension)
    • Other EPS
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Causes

  • Most common agents
    • Butyrophenones
    • Haloperidol
    • Phenothiazines
    • Thioxanthenes
    • Long-acting neuroleptics (benzamines)
    • Several other agents that reportedly have caused neuroleptic malignant syndrome - Tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), anticonvulsants, lithium, and dopamine antagonists (eg, metoclopramide, sulpiride)
  • Agent risk factors
    • Rapid initiation of antipsychotic therapy
    • Use of high-potency drugs (drug's potential for inducing neuroleptic malignant syndrome seems to parallel its antidopaminergic activity)
    • Depot preparations
  • Host risk factors
    • Age - People of all age groups affected (reported mean age is 40 y)
    • Sex - More common in men (2:1 ratio)
    • Concomitant illnesses
      • Organic brain disease or alcoholism
      • Dehydration, nutritional deficits
      • Affective disorder
      • Severe patient agitation or catatonia[4]
      • History of neuroleptic malignant syndrome
      • Simultaneous use of predisposing drugs (eg, lithium, anticholinergic agents)
  • Environmental risk factors: Environmental risk factors may include seasonality. Some investigators report higher incidence of neuroleptic malignant syndrome in summer in connection with heat stroke; other investigators have reported no seasonal clustering.
  • Caveats
    • Higher incidence of neuroleptic malignant syndrome with parenteral administration of neuroleptics was noted in one study.
    • Coadministration of anti-Parkinson drugs and neuroleptics effectively prevents neuroleptic malignant syndrome, according to one investigator; however, another investigator found no such benefit. Withdrawal of parkinsonian medication is reported to be one etiological factor for neuroleptic malignant syndrome.
    • Not all patients have recurrent neuroleptic malignant syndrome, even if the same neuroleptic is administered in the same dose after recovery from neuroleptic malignant syndrome.
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Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Coauthor(s)

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.

Specialty Editor Board

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 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.

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.

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.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

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.

References

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