[The neuroleptic malignant syndrome].

Dear Editor, The clinical features of an uncommon hypersensitivity to neurolepitcs were first described by Preston, 1 and was subsequently known as neuroleptic malignant syndrome (NMS). The incidence of NMS report elsewhere is between 0.07% 2 7 and the mortality rate is up to 25%. 8, 9 The condition appears to be an idiosyncratic reaction to a therapeutic dose of the antipsychotic drugs especially dopamine receptor antagonists and a dose relationship has been postulated. 10, 11 Despite the sporadic occurrence of NMS in our psychiatric units, no case has been reported from Nigeria. A 21-year-old female nurse who was Gravida 1, Para 1+ developed acute postpartum psychosis of manic type, two days following childbirth. She developed the psychosis on a background of normal personality and absence of any family history of psychiatric or neurological illness. She was initially admitted at a general hospital, where she works. On admission, she was given massive dose of chlorpromazine and paraldehyde intramuscularly (the relations could not ascertain the amount of dosage given). On the third day of admission, she became more restless, confused, pyrexic and developed generalized stiffness. She was transferred to another hospital where a lumbar puncture was done to exclude meningitis, but the cerebrospinal fluid was normal. She was then referred for electroencephalogram (EEG) to exclude organic brain disease. By the time the patient was brought to the EEG clinic, her temperature was 42c and she had marked body rigidity of plastic type with occasional choreoform movement of the limbs and in addition was comatose. Pulse rate was 110 per minute, regular and normal volume and blood pressure 140/95mmHg. The EEG showed diffuse mixture of fast and slow waves and the background activity consisted of muscle artifact on all channels and NMS was suspected. Blood samples were taken for complete blood count, serum electrolytes and urea, liver function tests and serum creatine kinase. All neuroleptic drugs were discontinued and she was moved into an airconditioned room and tepid sponged with water. Bromocriptine was commenced (10mg 6 hourly) along with 10mg diazepam 6 hourly and benzhexol 5mg 8 hourly. All the medications were given intramuscularly for the first 48 hours and orally by nasogastric tube. By the second temperature dropped to 37.5c, blood pressure remained 140/90 mmHg and level of consciousness improved. By this time laboratory results became available; haemogram was 11.5g/dl, white cell count 11.3 x 10/L; serum sodium was 140mmol/l, potassium 6.0mmoI/l, urea 20mg%, aspertate transaminase 50 iu/l, erythrocyte sedimentation rate 22mm/hr and creatine kinase 3600 iu/l. On the 4 day, temperature was normal, and she could recognize familiar people and was able to speak. Her body rigidity became less and she was able to walk with some help. By the 7 day, the patient started becoming restless and talkative, as a result she was placed on thioridazine 100mg 12 hourly. The physical and mental condition continued to improve and by the third week, she was well enough and was discharged home on thioridiazine 100mg bd. She has remained well and now has 4 lovely children. The clinical features, of hyperpyrexia, generalized body rigidity with choreoform movements of the limbs, elevation of creative kinase and evidence of acidosis following massive ingestion of neuroleptic is in conformity with the diagnosis of NMS, as reported elsewhere. 8 12 The presence of abnormal EEG is additional finding in support of our diagnosis. Because of the difficulty of availability of drugs such as dantrolene in our environment, we resorted to using a modified form of tepid sponging with ordinary water to facilitate lowering of the body temperature, and we advocate the use of this procedure especially in difficult environment such as is found in African regions. Attempt used at reducing the muscle rigidity was achieved by the use of benzodiazepines and anticholinergics which are easily available in our environment. The choice of thioridazine to treat her psychotic state was mainly for its anticholinergic advantage, which was facilitated by the addition of benzhezol. This combination we believed was relatively safer than other psychotropics available to us, as the result of treatment has shown.