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Neuroleptic malignant syndrome

Last reviewed: 12 Nov 2024
Last updated: 08 Nov 2022

Summary

Definition

History and exam

Key diagnostic factors

  • history of exposure to antipsychotic medications
  • history of abrupt withdrawal of dopaminergic drugs
  • history of structural brain abnormality
  • altered mental status
  • muscle rigidity
  • autonomic dysfunction
  • hyperthermia
  • psychiatric history
Full details

Other diagnostic factors

  • history of iron deficiency
  • history of Wilson disease
Full details

Risk factors

  • exposure to antipsychotic medications
  • structural brain abnormality
  • abrupt withdrawal of dopaminergic drugs
  • older age
  • preexisting agitation
  • akathisia
  • male sex
  • iron deficiency
  • catatonia
  • preexisting dehydration
  • exposure to dopamine antagonists and other antipsychotics
Full details

Diagnostic tests

1st tests to order

  • CBC
  • serum creatine kinase
  • basic metabolic panel
  • brain CT scan
  • brain MRI
  • myoglobin levels and urinalysis
  • urine culture
  • blood culture
  • lumbar puncture
  • toxicology screen
  • chest x-ray
Full details

Tests to consider

  • serum iron
  • electroencephalogram
Full details

Treatment algorithm

ACUTE

initial episode

ONGOING

recurrence

Contributors

Authors

Ronald J. Gurrera, MD

Associate Professor

Harvard Medical School

Boston

MA

Disclosures

RJG declares that he has no competing interests.

Acknowledgements

Dr Ronald J. Gurrera would like to gratefully acknowledge Dr Peter F. Buckley, a previous contributor to this topic.

Disclosures

PFB is on the advisory board (a voluntary, uncompensated role) of the Neuroleptic Malignant Syndrome Information Service. He is also a consultant to Janssen Pharmaceutica and the National Institute of Mental Health (NIMH). He is conducting or has recently conducted research with funding support from AstraZeneca, NIMH, Janssen Pharmaceutica, Pfizer, Solvay, and Wyeth. Previous consultancy and research support has been from Abbott, Alamo Pharmaceuticals, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Lundbeck, Janssen Pharmaceutica, Merck, NIMH, Roche Diagnostics, Pfizer, Solvay, and Wyeth. PFB has no patents or stock in any company. He is an author of several references cited in this topic. PFB is a co-investigator on a study also involving Dr John Lauriello and Dr Daniel R. Wilson, who were reviewers for this topic.

Peer reviewers

Alison Haddow, MBBS

Consultant Psychiatrist

Honorary Senior Clinical Lecturer

Royal Cornhill Hospital

Aberdeen

UK

Disclosures

AH declares that she has no competing interests.

John Lauriello, MD

Professor and Chair

Department of Psychiatry

University of Missouri-Columbia

Columbia

MO

Disclosures

JL declares that he has no competing interests.

Ganesh Gopalakrishna, MD

Assistant Professor

Department of Psychiatry

University of Missouri-Columbia

Columbia

MO

Disclosures

GG declares that he has no competing interests.

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