Case Presentation

Case PresentationDone by:Al Yaqdhan Al Atbi, MDEM resident R1

OutlineCase ScenarioClinical approach

Case discussion:Differential diagnosisInvestigations Management

Case scenario53yrs old lady brought by the family with history of altered mental status and fever since 2 days.

Vitals :PR120; RR30; SpO2 85; BP 105/56T: 36.8

How would like to Proceed?

TEAM LEADER

Airway :Patent , clear mouth

Breathing :RR 35, SpO2 85%Rt lower chest bilateral course crepitation

Circulation:BP 105/55; PR 120; severely dehydratedPeripheral sweaty and warm extremitiesPeripheral pulses are all palpable

Disability:GCS:12 ( E4V4M4 )Pupils : constricted ,equally reactive Reflu 14.5

Exposure:No skin rashes No signs of trauma , bruises

History53yrs old lady :Confusion, headache Fever : documented 38.5 , chills and rigorCough : productive of yellowish sputum, SOBVomiting >5 times, food content, no bloodUrine: dysuria

Past Medical History:Psychiatric disorder Diabetes Miletus HTN

Medication Hx : (not sure about it)Haloperidol 5mg BID Chloropomazine 100mg BIDValoprate Sodium 200mg BIDMetformin 1g BID

UDS: nitrate +, RBC+++, ketone +++++

6

ExaminationConfused , in distressVitals same as previousChest : same findings , SpO2 95%Abdomen : soft non tenderCNS:GCS 12/15Pupils reactive equalnormal reflexes in all limbsPower normal Toe down goingNo meningeal signs

LabsVBG: normal pH, HCO3 and pCO2Lactate: 4.2

Hb 11.3; WBC 8.7; ANC 7.8CRP 51eGFR: 68; Cr77; Ur 6.1Na 140; K 4.3

X ray chest

InterventionsStarted on :Antibiotic cover , hydration , antipyretics

Impression:CAPUTI CNS infection

Referred to medicine.

Second Day In ED: Medical team Morning round, the plan was to resume her regular medications Haloperidol 5mg BID.Chloropomazine 100mg BID.Valoprate Sodium 200mg BID.Metformin 1g BID.

After 12 hours she was noted :More confused , sweatyVitals : PR 120; T39.4 ; RR20Has upper limb cogwheel rigidity

What is the cause of her new symptoms??

Deferential DiagnosisSepsis:PneumoniaUTICNS infection: viral encephalitis Stroke Neuroleptic Malignant Syndrome NMS

Neuroleptic Malignant Syndrome NMS

NMSA rare but potentially fatal idiosyncratic complication of anti-psychotic drug therapy

Occur usually due to:Initiation of new antipsychotic Increase dose of antipsychotic

Both typical and atypical Antipsychotic can cause NMS

Onset from hours to days.16% : within 24hrs.66% : within 1 week.Virtually all cases : within 30 days.

Clinical PresentationClassical tetrad of clinical features

Risk Factors:AgitationDehydrationCatatonia Iron deficiencyPrior episode of NMS :20%external heat load

Antipsychotic related Risk factors:Typical > atypical antipsychotic IV> POHigh dose> low dose

InvestigationsFBC Leucocytosis (WBC 10000-40000)

CK elevated (> 1000 IU/L)

Urine analysis myoglobinuria indicate poor prognosis.

ABG Metabolic acidosis

Serum iron reduced ( ? An acute phase response)

Serum catecholamine - elevated

CSF 95% normal.

Brain imaging usually normal.

EEG generalized slowing.(metabolic encephalopathy)

ManagementImmediate withdrawal of the offending agent.

Reinstitution of abruptly withdrawn dopaminergic agents.

Supportive care mainstay of managementAggressive fluid resuscitationMonitoring and correction of electrolyte imbalances.Cooling measures (eg: cooling blankets, ice packs) in extreme hyperthermia.Dialysis renal failureVentilator support respiratory failure

Management cont..Benzodiazepine:Indications:Agitation, psychomotor hyperactivity, and muscle rigidity Lorazepam: Starting dose 1-2mg IM/IV every 3 minutes, until muscle rigidity improves.

Refractory cases or cases at risk for aspiration:RSI and NMB agents with a nondepolarizing agent (e.g., rocuronium and vecuronium)

Dopaminergic agents

BromocriptineDopamine agonistStarting dose - 2.5mg BID oral/NG Increase dose by 2.5mg every 24hrs.Max. dose 45mg/day

Amantadine 200-400mg/day in divided doses oral/NG

Dantrolene:Inhibits the release of calcium from the sarcoplasmic reticulumhas no proven benefit.

Management cont..ECT can be effective in,

Poor response to supportive care and pharmacological management.When idiopathic malignant catatonia cannot be excluded.Persistent residual catatonia and parkinsonism after the resolution of acute symptoms.

Antipsychotic use after NMSEstimated risk of 30% of developing NMS again with re-introduction of antipsychotics.

Precautions:At least 2 weeks should be allowed from recovery before re-challenge.Low potency conventional antipsychotics/ atypical antipsychotics.Start with a low dose and titrate gradually.Careful monitoring for early signs of NMS.

Antipsychotic medicationsAka neurolepticsatypical antipsychotics are as effective as typical antipsychotics but have better side effect profileRoute: PO; short-acting or long-acting depot IM injections; sublingual

Extrapyramidal Symptoms (EPS)

Home messageConservative use of antipsychotics.

Reduction of risk factors.

Early diagnosis.

Prompt discontinuation of offending agents.

Early supportive care and medical management.

References Tintinallis EMRosens 8th edition Toronto Notes Medscape

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