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CASE REPORT OPEN ACCESS
Journal of the College of Physicians and Surgeons Pakistan 2022, Vol. 32 (Supplement 1):S47-S48 S47
Neuroleptic Malignant Syndrome with Normal Creatine
Phosphokinase Levels: An Atypical Presentation
Saba Zaidi, Nashit Irfan and Zain Khalid
Department of Neurology, Liaquat National Hospital and Medical College, Karachi, Pakistan
ABSTRACT
Neuroleptic malignant syndrome (NMS) was initially notified as an adverse effect of an antipsychotic agent called chlorpro-
mazine, in 1956. In the past, several case reports of NMS have been reported, even if they did not meet the proposed diag-
nostic criteria for it. The diagnostic criteria for NMS include increased muscle stiffness, increased body temperature, elevated
creatine phosphokinase (CPK) levels by at least four times the upper limit of normal (ULN), autonomic dysfunction, and an
altered mental status.
We present a case of a 25-year gentleman with schizophrenia, who arrived in the Emergency Department, with significant
behavioural changes for a month, accompanied by drowsiness and high-grade fever for two weeks. CPK levels done on two occa-
sions were 669 U/L and 710 U/L, respectively. Persistent hyperthermia and autonomic symptoms with further deterioration in
mental status, led to a working diagnosis of NMS. The patient, thereafter, received bromocriptine, benzodiazepines and contin-
uous intravenous hydration, but his clinical condition deteriorated and he expired after nine days of hospital stay.
Key Words: Neuroleptic malignant syndrome, Creatine phosphokinase, Hyperthermia, Muscle stiffness.
How to cite this article: Zaidi S, Irfan N, Khalid Z. Neuroleptic Malignant Syndrome with Normal Creatine Phosphokinase Levels: An
Atypical Presentation. J Coll Physicians Surg Pak 2022; 32(Supp1):S47-S48.
INTRODUCTION
Neuroleptic malignant syndrome (NMS) is a potentially life-
threatening, neuroleptic-induced idiosyncratic reaction, char-
acterised by muscle stiffness, increased body temperature,
elevated creatine phosphokinase (CPK) levels, autonomic
dysfunction, increased white blood cell (WBC) count, and an
altered mental status.1 Global estimates from a review have
shown an overall estimate of 0.991 cases per 1,000 people;
whereas, the incidence in Pakistan remains understudied.2
NMS has been associated with significant death rate or perma-
nent damage, which highlights the need for its early diagnosis
and treatment.3,4
We, herein, present a case of a 25-year gentleman with schi-
zophrenia, who arrived in the Emergency Department, with
significant behavioural changes for a month, accompanied by
drowsiness and high-grade fever for two weeks. He was diag-
nosed with NMS and managed accordingly, but we were not
able to save his life.
Correspondence to: Dr. Saba Zaidi, Department of
Neurology, Liaquat National Hospital and Medical
College, Karachi, Pakistan
E-mail: drsabazaidi@gmail.com
.....................................................
Received: March 03, 2020; Revised: May 30, 2020;
Accepted: June 15, 2020
DOI: https://doi.org/10.29271/jcpsp.2022.Supp1.S47
CASE REPORT
We present a case of a 25-year gentleman with schizophrenia,
who arrived in the Emergency Department, with significant
behavioural changes for a month, accompanied by drowsiness
and high grade fever for two weeks.
Detailed history revealed that the patient was having a low
mood and lack of interest in his work and relationship for the
past two years. A month ago, he became aggressive, verbally
and physically abusive towards his family members, throwing
objects at them and not recognising them. For this change in
behaviour, he was started with anti-psychotics and benzodi-
azepines (haloperidol, olanzapine, and clonazepam). Later,
medications were adjusted in accordance with his psychotic
episodes. His brother added that he had received anti-psy-
chotics in the injectable form together with electro-convulsive
therapy for the control of his psychotic symptoms.
On admission, the vitals were: Temperature 101°F, heart rate 120
beats/minute, respiratory rate 18 breaths/minute, and blood pres-
sure 120/80 mmHg. The patient was lean and thin, drowsy,
grimacing on pain; his pupils were 3mm in diameter, and sluggish
in reaction. There was an increase in muscle tone all over and
remarkable axial rigidity (neck stiffness in all directions). Labora-
tory workup revealed hemoglobin 15.7 g/dL, total leukocyte count
(TLC) 13,500/uL, platelets 264,000/mm3, urea 51 mmol/L, creati-
nine 0.99 mg/dL, sodium 146 mmol/L, potassium 3.8 mmol/L, and
bicarbonate 26 mmol/L. Furthermore, CPK levels done on two occa-
sions were 669 U/L and 710 U/L, respectively. Magnetic resonance
imaging (MRI) brain was unremarkable and electroencephalo-
Saba Zaidi, Nashit Irfan and Zain Khalid
Journal of the College of Physicians and Surgeons Pakistan 2022, Vol. 32 (Supplement 1):S47-S48
S48
gram (EEG) showed slow posterior dominant rhythm. Cere-
brospinal fluid (CSF) detailed report showed glucose to be 93
mg/dL (normal: 50-80 mg/dL), protein 27 mg/dL (normal: 15-45
mg/dL), and WBC count 4/mm3 (normal: 0-8/mm3) and red blood
cell (RBC) count 323/mm3.
The patient on arrival was admitted under the psychiatry services,
and was given broad-spectrum antibiotics for a possible central
nervous system (CNS) infection. Later, persistent hyperthermia
and autonomic symptoms with further deterioration in mental
status led to a working diagnosis of NMS.
The patient, thereafter, received bromocriptine, benzodiazepines
and continuous intravenous hydration, but his clinical condition
deteriorated and he expired nine days after hospital admission.
DISCUSSION
To establish the diagnosis of NMS in a patient, several signs and
symptoms have been reported over the years. Among these,
some of the widely accepted ones are those suggested by Pope et
al, DSM-IV-TR, Caroff et al.; and in all of these, serum CPK eleva-
tion is not included as a major criterion.5-7
Additionally, Levenson also put forward a diagnostic criterion
that suggests the presence of either three major criteria (ele-
vated CPK levels, increased body temperature, muscle stiffness)
or two major with at least four minor manifestations.8
Our patient
fell under the latter. He had elevated body temperature, stiff
muscles (major) and also elevated WBC counts, increased
sweating, rapid heart rate, rapid breathing and an altered mental
state (minor). The patients of NMS normally present with
elevated CPK levels, typically more than 1,000 U/L.9 In our
patient, serum CPK titers tested were not that high, on both occa-
sions, which led to the unique finding of this case. The possible
cause behind the lack of elevation of CPK levels was the low BMI
(body mass index) of our patient, similar to a case previously
reported in the literature.10
From this case, we also track that the patient was developing
mental symptoms like low mood and lack of interest for two
years; and his family still did not get any form of help from psychia-
trists, until his condition was exacerbated. The lack of confidence
in terms of identifying mental illnesses, at an early stage by our
community and in terms of seeking help with so much delay, goes
to show how such illnesses are still a social stigma and taboo in
Pakistan.11
Furthermore, clinical practitioners like psychiatrists and physi-
cians should be made aware that the conditions like NMS are a
possible complication of antipsychotics, so they are more judicial
before prescribing high doses of these drugs in patients with
mental illnesses. Perhaps these shortcomings in knowledge and
practices of NMS can be attributed to the lack of research in our
region and appropriate guidelines for the prompt management
of mental conditions without inadvertently bringing about more
harm to the patient.
Although diagnostic criteria for NMS have been established,
widely accepted and applied, this condition still poses a diag-
nostic dilemma, as CPK levels may not be as high as expected.
Diagnosis of NMS should still be considered in appropriate circum-
stances.
PATIENT’S CONSENT:
Informed consent was obtained from the patient.
CONFLICT OF INTEREST:
The authors declared no conflict of interest.
AUTHORS’
CONTRIBUTION:
SZ: Writing, editing, designing, reviewing.
NI, ZK: Writing, designing.
REFERENCES
Gurrera RJ, Caroff SN, Cohen A, Carroll BT, DeRoos F,1.
Francis A, et al. An international consensus study of
neuroleptic malignant syndrome diagnostic criteria using
the Delphi method. J Clin Psychiatry 2011; 72(9):1222–8.
doi: 10.4088/JCP.10m06438.
Gurrera RJ, Simpson JC, Tsuang MT. Meta-analytic evidence2.
of systematic bias in estimates of neuroleptic malignant
syndrome incidence. Compr Psychiatry 2007; 48(2):
205-11. doi: 10.1016/j.comppsych.2006.10.004.
Shalev A, Hermesh H, Munitz H. Mortality from neuroleptic3.
malignant syndrome. J Clin Psychiatry 1989; 50(1):18-25.
Adityanjee, Sajatovic M, Munshi KR. Neuropsychiatric4.
sequelae of neuroleptic malignant syndrome. Clin
Neuropharmacol 2005; 28(4):197-204. doi: 10.1097/
01.wnf.0000172079.80795.5f.
Pope H, Keck P, McElroy S. Frequency and presentation of5.
neuroleptic malignant syndrome in a large psychiatric
hospital. Am J Psychiatry 1986; 143(10):1227-33. doi:
10.1176/ajp.143.10.1227.
American Psychiatric Association. Diagnostic and statistical6.
manual of mental disorders, 4th edition (DSM-IV). American
psychiatric association 1994.
Caroff S, Mann S, Lazarus A, Sullican K, MacFadden W.7.
Neuroleptic malignant syndrome: Diagnostic
issues. Psychiatr Ann 1991; 21:130-47.
Levenson JL. Neuroleptic malignant syndrome. Am J8.
Psychiatry 1985; 142(10):1137.
Adnet P, Lestavel P, Krivosic-Horber R. Neuroleptic9.
malignant syndrome. Br J Anaesth 2000; 85(1):129-35.
doi: 10.1093/bja/85.1.129.
Nisijima K, Shioda K. A rare case of neuroleptic malignant10.
syndrome without elevated serum creatine kinase.
Neuropsychiatr Dis Treat 2014; 10:403. doi: 10.2147/
NDT.S58677.
Khan F, Knan A, Shezad RK, Sidiq H, Khan NS. Developing11.
child and adolescent paediatric liaison service in Lahore,
Pakistan. J Pak Psychiatr Soc 2009; 6(1):42.
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