benztropine and Neuroleptic-Malignant-Syndrome

Patients who present with acute neuropsychiatric syndromes pose difficult diagnostic and treatment challenges. A history of psychiatric illness and treatment with psychotropic medication may be valuable clues to diagnosis and management of such patients. However, this information may also tempt a clinician to focus on a premature diagnosis, excluding other important possibilities. A case of a 42-year-old male with recurrent psychotic illness who developed an abrupt deterioration in mental and physical status is presented. Despite an initial good response to physostigmine, he was diagnosed with neuroleptic malignant syndrome and did not receive subsequent treatment with cholinesterase inhibitors. The patient expired within hours of arriving in the emergency room. The postmortem benztropine level was elevated, leading to the attribution of death to anticholinergic toxicity. This case serves to illustrate the difficulties in distinguishing features of anticholinergic toxicity and neuroleptic malignant syndrome.

Topics: Adult; Antipsychotic Agents; Benztropine; Catatonia; Cholinergic Antagonists; Diagnosis, Differential; Dose-Response Relationship, Drug; Drug Therapy, Combination; Fatal Outcome; Humans; Male; Neuroleptic Malignant Syndrome; Psychotic Disorders

Antipsychotic agents are widely used for the treatment of psychotic disorders as well as for the acute treatment of nausea and vomiting, cough and cold treatments, and as supplementary agents for sedation for minor surgical or diagnostic procedures. There are many different circumstances in which the clinician may encounter a child who has experienced antipsychotic drug toxicity, such as from an acute accidental ingestion or as a side effect from therapeutic use. The phenothiazines and butyrophenone drugs have many pharmacologic actions. Thus, a wide range of clinical symptoms and signs may be encountered with their use. Treatment of antipsychotic drug toxicity includes general supportive care and monitoring, along with specific treatment of certain situations such as acute extrapyramidal syndromes and neuroleptic malignant syndrome. An awareness of the diverse and complex manifestations that may be associated with these agents will greatly aid in the evaluation of a child who presents with unusual behavioral or neurologic problems. Due to the unpredictable toxicity of these drugs, routine therapeutic use for such conditions as nausea and vomiting and as cough or cold aids is not recommended.

Topics: Absorption; Adolescent; Basal Ganglia Diseases; Benztropine; Butyrophenones; Cardiovascular System; Central Nervous System; Charcoal; Chemical and Drug Induced Liver Injury; Child; Child, Preschool; Coma; Dantrolene; Diagnosis, Differential; Diphenhydramine; Female; Gastric Lavage; Humans; Ipecac; Kinetics; Liver; Neuroleptic Malignant Syndrome; Phenothiazines; Photosensitivity Disorders

The neuroleptic malignant syndrome (NMS) is a rare but potentially lethal disorder associated with the administration of neuroleptic agents. This syndrome may be underdiagnosed because it is poorly understood and often unrecognized. It affects all age groups and has a 20% mortality. Presenting features include extrapyramidal symptoms, altered mental consciousness, autonomic dysfunction, and hyperthermia. The underlying explanation for these manifestations is a disturbance of the dopaminergic system within the basal ganglia and hypothalamus. Dantrolene (Dantrium), amantadine (Symmetrel), and bromocriptine mesylate (Parlodel) have been efficacious in conjunction with supportive therapy. I report three cases successfully treated with bromocriptine and supportive therapy.

Topics: Adolescent; Adult; Benztropine; Bromocriptine; Catatonia; Child; Child, Preschool; Diagnosis, Differential; Female; Fluphenazine; Haloperidol; Heat Exhaustion; Humans; Male; Malignant Hyperthermia; Middle Aged; Neuroleptic Malignant Syndrome; Psychotic Disorders; Schizophrenia, Paranoid; Time Factors

Topics: Adult; Aggression; Antipsychotic Agents; Aripiprazole; Benzodiazepines; Benztropine; Dose-Response Relationship, Drug; Drug Therapy, Combination; Humans; Intellectual Disability; Male; Neuroleptic Malignant Syndrome; Neurologic Examination; Olanzapine; Piperazines; Quinolones; Risk Factors

Topics: Benztropine; Bipolar Disorder; Cytochrome P-450 CYP2D6 Inhibitors; Drug Interactions; Drug Therapy, Combination; Female; Humans; Lithium Compounds; Middle Aged; Neuroleptic Malignant Syndrome; Paroxetine; Perphenazine; Psychotropic Drugs; Trazodone

Neuroleptic Malignant Syndrome (NMS) is a life-threatening adverse reaction arising from the use of neuroleptic medications. While dopaminergic agonists, dantrolrene and supportive care are traditionally utilized in the stabilization and management of NMS, anticholinergic medication may also prove effective therapy. Treatment with anticholinergic medication has been suggested in cases of NMS associated with mild hyperthermia. We describe a case of 17-y-old female, who was brought to the emergency department for a possible "acute dystonic reaction". The patient received 50 mg diphenhydramine i.v., which resulted in improvement in mental status. The patient was readmitted to the emergency department 1 d following discharge with symptoms similar, but now considering the diagnosis of NMS. Diphenhydramine 50 mg i.v. was again administered and resulted in significant improvement.

Topics: Adolescent; Benztropine; Cholinergic Antagonists; Diphenhydramine; Female; Fever; Fluphenazine; Humans; Lithium Chloride; Neuroleptic Malignant Syndrome

Topics: Akathisia, Drug-Induced; Benztropine; Bipolar Disorder; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Therapy, Combination; Female; Humans; Lithium Carbonate; Middle Aged; Neuroleptic Malignant Syndrome; Neurologic Examination; Paroxetine; Perphenazine; Receptors, Serotonin; Trazodone

Topics: Adult; Benztropine; Bipolar Disorder; Coma; Diagnosis, Differential; Drug Therapy, Combination; Haloperidol; Humans; Lithium; Male; Neuroleptic Malignant Syndrome

Topics: Adult; Benztropine; Bromocriptine; Drug Therapy, Combination; Humans; Male; Muscle Rigidity; Neuroleptic Malignant Syndrome; Tropanes