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BACKGROUND: Anti-N-methyl-D-aspartate receptor encephalitis (ANMDARE) is a neuroimmunological disorder that frequently improves with immunotherapy. Symptomatic treatment with antipsychotics is common in the early stages when psychiatric symptoms predominate, and their use has been associated with serious side effects including neuroleptic malignant syndrome (NMS). The observation of an adverse response to antipsychotics, raising the suspicion of NMS, has been included as a criterion for possible autoimmune psychosis. METHODS: This case-control study included patients who received antipsychotics before referral to the National Institute of Neurology and Neurosurgery of Mexico, where they were diagnosed as having definite ANMDARE, and patients with ANMDARE who did not receive antipsychotics before referral. The neurologic and systemic features that are used to measure an adverse response to antipsychotics, raising the suspicion of NMS, were measured in both groups, including akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, and hyperthermia. A logistic regression analysis was used to determine the relationship between the previous use of antipsychotics and the occurrence of NMS-like reactions. RESULTS: A total sample of 112 patients with definite ANMDARE were included in the study. Fifty patients received antipsychotics before being referred to our institution. In this group, thirty-six patients (72%) were initially classified as having an adverse response, raising the suspicion of NMS, with the following features: akinesia (64%), autonomic instability (58%), generalized rigidity (52%), elevated concentrations of creatine phosphokinase (50%), and hyperthermia (14%). Six patients fulfilled the criteria for NMS (12%). The comparison with patients who did not receive antipsychotics before the clinical assessment did not show a significant difference between groups regarding the frequency of akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, or hyperthermia. Among different antipsychotics, only haloperidol was significantly associated with generalized rigidity as compared to patients who did not receive antipsychotics. CONCLUSIONS: Our study supports previous observations about the high frequency of autonomic dysfunction, hyperthermia, tachycardia, rigidity, and elevated creatine phosphokinase levels in patients with anti-NMDAR encephalitis following the administration of antipsychotic medications. Nevertheless, our study does not suggest a causal link between atypical antipsychotics and the onset of these neurological symptoms, as they were equally frequent among the group of patients who did not receive antipsychotic treatment.

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ABSTRACT Neuroleptic malignant syndrome (NMS) is a neurologic emergency potentially fatal. This rare side effect is most commonly associated with first-generation antipsychotics and less frequently with atypical or second-generation antipsychotics. The diagnosis relies on both clinical and laboratory criteria, with other organic and psychiatric conditions being ruled out. CASE REPORT: A 39-year-old female patient, who is institutionalized and completely dependent, has a medical history of recurrent urinary infections and colonization by carbapenem-resistant Klebsiella pneumoniae. Her regular medication regimen included sertraline, valproic acid, quetiapine, risperidone, lorazepam, diazepam, haloperidol, baclofen, and fentanyl. The patient began experiencing dyspnea. Upon physical examination, she exhibited hypotension and a diminished vesicular murmur at the right base during pulmonary auscultation. Initially, after hospitalization, she developed high febrile peaks associated with hemodynamic instability, prompting the initiation of antibiotic treatment. Despite this, her fever persisted without an increase in blood inflammatory parameters, and she developed purulent sputum, necessitating antibiotherapy escalation. The seventh day of hospitalization showed no improvement in symptoms, suggesting NNMS as a differential diagnosis. All antipsychotic and sedative drugs, as well as antibiotherapy, were discontinued, after which the patient showed significant clinical improvement. CONCLUSION: Antipsychotic agents are commonly employed to manage behavioral changes linked to various disorders. However, their severe side effects necessitate a high degree of vigilance, the cessation of all medications, and the implementation of supportive care measures. A prompt and accurate diagnosis of NMS is crucial to alleviating the severe, prolonged morbidity and potential mortality associated with this syndrome.

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Patients in adult psychiatric wards present infectious complications or pathologies that mimic an infectious condition, and there is little information on this subject. OBJECTIVES: To know the frequency and infectious and non-infectious complications treated by infectious disease specialists in a psychiatric intensive-care hospitalization unit for adults and their outcomes. METHODS: Observational study between 2016 and 2021. RESULTS: 37 patients with 41 events were evaluated. Almost half of the visits to these events originated from an antimicrobial stewardship program (46.3%). In 68.3% of the events, complementary studies were requested; in 14.6%, referral to other specialties; in 26.8%, an antimicrobial treatment was started; and in 75%, modifications were made to previous schemes. An infectious cause was identified in 30 of 41 events (73.2%) that included the following conditions: respiratory (31.7%), skin (9.8%), urinary (7.3%), gynecological (2.4%), one case of bacteremia with unknown source (2.4%), sequential infections (4.9%) and HIV therapy dropouts (7.3%). In the 11 remaining events, non-infectious causes were identified (26.8%): pulmonary thromboembolism, drug hepatotoxicity, false positive VDRL and HIV tests, steroid-induced psychosis in an HIV patient with thrombocytopenia, fever without etiology, residual positive SARS-CoV-2 PCR test, low O2 pulse oximetry due to oversedation and neuroleptic malignant syndrome. There was no mortality. CONCLUSIONS: Patients in psychiatric hospitalization wards suffer from a great diversity of infectious problems during their stay with conditions that simulate infections. An antibiotic surveillance system can detect half of these conditions. The infectious diseases visits allow for advising or reorienting of the study and modifying the antibiotic treatment.

Los pacientes en salas de hospitalización psiquiátricas de adultos presentan complicaciones infecciosas o patologías que simulan un cuadro infeccioso y existe escasa información sobre este tema. OBJETIVOS: Conocer la frecuencia y tipo de complicaciones infecciosas y no infecciosas atendidas por especialistas de infectología en un Servicio de hospitalización psiquiátrica de cuidados intensivos de adultos y sus desenlaces. MÉTODOS: Estudio observacional entre el 2016 y 2021. RESULTADOS: Se visitaron 37 paciente con 41 eventos. Casi la mitad de las visitas en estos eventos se originó por seguimiento de antimicrobianos (46,3%). En el 68,3% de los eventos se solicitaron estudios complementarios, en 14,6% la opinión de otras especialidades, en 26,8% se inició un tratamiento antimicrobiano y en 75% se hicieron modificaciones a esquemas previos. En 30 de 41 eventos se identificó una causa infecciosa (73,2%) que incluyeron las siguientes condiciones: respiratorias (31,7%), cutáneas (9,8%), urinarias (7,3%), ginecológicas (2,4%), bacteremia sin foco (2,4%), infecciones secuenciales (4,9%) y abandonos de terapia en pacientes VIH (7,3%). En los 11 eventos restantes se identificaron causas no infecciosas (26,8%): tromboembolismo pulmonar, hepatotoxicidad por drogas, test VDRL y VIH falsos positivos, psicosis por esteroides en un paciente VIH con trombocitopenia, fiebre sin etiología, PCR SARS-CoV-2 positiva residual, desaturación de O2 por sedación y síndrome neuroléptico maligno. No hubo mortalidad en esta serie. CONCLUSIONES: Los pacientes en salas de hospitalización psiquiátrica sufren de una gran diversidad de problemas infecciosos durante su estadía junto a cuadros que simulan infecciones. Un sistema de vigilancia antibiótica permite detectar la mitad de estas condiciones. Las visitas infectológicas permiten asesorar o reorientar el estudio y modificar el tratamiento antibiótico.

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El síndrome neuroléptico maligno (SNM) es una reacción adversa medicamentosa potencialmente fatal asociada comúnmente a medicamentos antipsicóticos. Este artículo presenta una revisión actualizada sobre el SNM, aborda su epidemiología, factores de riesgo, presentación clínica, posibles mecanismos subyacentes y tratamiento. Se busca mejorar el reconocimiento temprano, diagnóstico y manejo del SNM en el ámbito clínico para reducir su morbimortalidad. La búsqueda de literatura se realizó en PubMed, fueron priorizados ensayos aleatorizados, revisiones sistemáticas, estudios retrospectivos y reportes de caso. La incidencia del SNM ha disminuido en los últimos años, posiblemente debido a una mejor prescripción y titulación de la medicación. Los factores de riesgo incluyen el uso de antipsicóticos de alta potencia, dosis elevadas, incremento rápido de la dosis y uso de antipsicóticos inyectables de depósito. Se han identificado factores ambientales como la deshidratación, sujeción mecánica y temperaturas extremas. Algunas características psicopatológicas, como la agitación psicomotriz y la confusión, también se han asociado al SNM. Los factores hereditarios y los polimorfismos genéticos pueden influir en la susceptibilidad al SNM, pero se requieren estudios adicionales. La fisiopatología del SNM se relaciona con el bloqueo excesivo de los receptores dopaminérgicos, pero otros cofactores y sistemas neurotransmisores también podrían estar involucrados. El cuadro clínico del SNM se caracteriza por cambios en el estado mental, rigidez muscular, hipertermia, síntomas catatónicos y sudoración profusa. Existen diversas formas de tratamiento, desde medidas generales hasta intervenciones farmacológicas.

The Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse drug reaction commonly associated with antipsychotic medications. This article presents an updated review of NMS, addressing its epidemiology, risk factors, clinical presentation, possible underlying mechanisms, and treatment. The aim is to improve early recognition, diagnosis, and management of NMS in the Peruvian clinical setting to reduce morbidity and mortality. The literature search was conducted in PubMed, prioritizing randomized studies, systematic reviews, retrospective studies, and case reports. The incidence of NMS has decreased in recent years, possibly due to better medication prescription and titration. Risk factors include the use of high-potency antipsychotics, high doses, rapid dose escalation, and the use of depot injectable antipsychotics. Environmental factors such as dehydration, mechanical restraint, and extreme temperatures have been identified. Some psychopathological characteristics, such as psychomotor agitation and confusion, have also been associated with NMS. Genetic factors and genetic polymorphisms may influence susceptibility to NMS, but further studies are needed. The pathophysiology of NMS is related to excessive blockade of dopaminergic receptors, but other cofactors and neurotransmitter systems may be involved. The clinical presentation of NMS is characterized by changes in mental status, muscle rigidity, hyperthermia, catatonic symptoms, and profuse sweating. There are various treatment approaches ranging from general measures to pharmacological interventions.

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Resumen: Uno de los efectos adversos más importantes de los neurolépticos es la posibilidad de desencadenar el síndrome neuroléptico maligno (NMS). El diagnóstico se determina por exclusión y el manejo terapéutico inicial será retirado por neurolépticos por la administración de benzodiacepinas y, en casos extremos, el uso de la terapia electroconvulsiva (ECT). La ECT es una opción terapéutica eficaz en estos pacientes y en esos casos se obtiene una mala respuesta a la administración con fármacos antipsicóticos. Basándonos en el caso del artículo «Rocuronium-sugammadex for electroconvulsive therapy management in neuroleptic malignant síndrome. A case report¼ donde se describe el manejo exitoso del uso de relajantes no despolarizantes y su reversor específico en terapias electroconvulsivas en pacientes diagnosticados de síndrome neuroléptico maligno, comentamos la fisiopatología e implicaciones anestésicas además de similitudes con otras entidades hipertérmicas, como es la hipertermia maligna.

Abstract: One of the most important adverse effects of neuroleptics is the possibility of triggering neuroleptic malignant syndrome (NMS). The diagnosis is determined by exclusion and the initial therapeutic management will be withdrawn by neuroleptics by the administration of benzodiazepines and, in extreme cases, the use of electroconvulsive therapy (ECT). ECT is an effective therapeutic option in these patients and in these cases a poor response to administration with antipsychotic drugs is obtained. Based on the case of the article «Rocuronium-sugammadex for the management of electroconvulsive therapy in neuroleptic malignant syndrome. A case report¼ where the successful management of the use of non-depolarizing relaxants and their specific reversal in electroconvulsive therapies in patients diagnosed with of malignant neuroleptic syndrome, we comment on the pathophysiology and anesthetic images as well as similarities with other hyperthermic entities, such as malignant hyperthermia.

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INTRODUCTION: Neuroleptic malignant syndrome (NMS) is uncommon, with an incidence of 0.01%-3.23%, and is associated with the use of drugs that intervene with dopamine, causing hyperthermia, muscular rigidity, confusion, autonomic instability and death. CASE REPORT: A 35-year-old man with a history of catatonia, refractory epilepsy and functional impairment, required frequent changes in his anticonvulsant and antipsychotic treatment, due to adverse effects. During 2019, in the month of July, clozapine was changed to amisulpride, in September he developed fever, muscle stiffness, stupor, diaphoresis and tachypnea over a two-week period; paraclinical tests showed elevated creatine phosphokinase (CPK) and leukocytosis, so NMS was considered. The antipsychotic was withdrawn and he was treated with bromocriptine and biperiden, with a good response. Ten days after discharge, he began treatment with olanzapine, which generated a similar episode to the one described in December, with subsequent management and resolution. DISCUSSION: The diagnosis is based on the use of drugs that alter dopamine levels, plus altered state of consciousness, fever, autonomic instability and paraclinical tests showing leukocytosis and elevated CPK. Differential diagnoses must be ruled out. Early diagnosis generally leads to total remission, although some patients will suffer complications, long-term sequelae or recurrences. The recurrence in this case derived from the early reintroduction of the neuroleptic after the first episode. Treatment should be individualised according to severity to avoid mortality. CONCLUSIONS: Atypical antipsychotics are rarely suspected of generating NMS. Moreover, the time to reintroduction after an episode must also be taken into account.

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Introducción: El síndrome neuroléptico maligno (SNM) es infrecuente, con una incidencia del 0,01 al 3,23%, y tiene relación con el consumo de fármacos que interfieren con la dopamina; genera hipertermia, rigidez muscular, confusión, inestabilidad autonómica y la muerte. Caso clínico: Un varón de 35 arios, con antecedentes de catatonía, epilepsia refractaria y deterioro funcional, en tratamiento anticonvulsivo y antipsicótico, requirió cambio frecuente por efectos adversos de este. En julio de 2019 se cambió la clozapina por amisulprida; en septiembre se inicia un cuadro de 2 semanas de fiebre, rigidez muscular, estupor, diaforesis y taquipnea; los paraclínicos mostraron aumento de la creatininasa (CK) y leucocitosis, por lo que se consideró SNM. Se retiró el antipsicótico y se trató con bromocriptina y biperideno, que obtuvieron buena respuesta. A los 10 días del egreso, se inició tratamiento con olanzapina, que generó en diciembre un cuadro clínico similar al descrito, con posterior tratamiento y resolución. Discusión: El diagnóstico se basa en la toma de fármacos que alteren la dopamina, más alteración del estado de conciencia, fiebre e inestabilidad autonómica, junto con paraclínicos como leucocitosis y elevación de la CK. Se debe descartar diagnósticos diferenciales. El diagnóstico temprano generalmente lleva a la remisión total; algunos tendrán complicaciones, secuelas a largo plazo o recidivas. La recurrencia en este caso derivó de la reintroducción temprana del neuroléptico después del primer episodio. El tratamiento se debe individualizar según la gravedad para evitar la muerte. Conclusiones: Rara vez se sospecha que los antipsicóticos atípicos generen SNM; a su vez se debe tener en cuenta el tiempo a la reintroducción después de un episodio.

Introduction: Neuroleptic malignant syndrome (NMS) is uncommon, with an incidence of 0.01% to 3.23%, and is associated with the use of drugs that intervene with dopamine, causing hyperthermia, muscular rigidity, confusion, autonomic instability and death. Case report: A 35-year-old man with a history of catatonia, refractory epilepsy and functional impairment, required frequent changes in his anticonvulsant and antipsychotic treatment, due to adverse effects. During 2019, in the month of July, clozapine was changed to amisul-pride, in September he developed fever, muscle stiffness, stupor, diaphoresis and tachypnea over a two-week period; paraclinical tests showed elevated creatine phosphokinase (CPK) and leukocytosis, so NMS was considered. The antipsychotic was withdrawn and he was treated with bromocriptine and biperiden, with a good response. Ten days after discharge, he began treatment with olanzapine, which generated a similar episode to the one described in December, with subsequent management and resolution. Discussion: The diagnosis is based on the use of drugs that alter dopamine levels, plus altered state of consciousness, fever, autonomic instability and paraclinical tests showing leukocy-tosis and elevated CPK. Differential diagnosis must be ruled out. Early diagnosis generally leads to total remission, although some patients will suffer complications, long-term sequelae or recurrences. The recurrence in this case derived from the early reintroduction of the neuroleptic after the first episode. Treatment should be individualised according to severity to avoid mortality. Conclusions: Atypical antipsychotics are rarely suspected of generating NMS. Moreover, the time to reintroduction after an episode must also be taken into account.

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Describimos la presentación clínica y dificultades diagnósticas de un caso de síndrome neuroléptico maligno en un hospital general. El paciente fue un varón de 18 años con diagnóstico de retraso mental grave e historia de convulsiones que recibía tratamiento irregular con risperidona y fenitoína. Tras presentar irritabilidad, agresividad y agitación psicomotriz acude a hospital psiquiátrico en donde le indican incremento de dosis de risperidona. Posteriormente por persistencia de agresividad, acude a hospital psiquiátrico en donde se indicó haloperidol, midazolam y levomepromazina, a los pocos días presentó distonía oro mandibular, alza térmica y distonía generalizada con dificultad para la deglución de alimentos, motivo por el cual acudió a hospital general y fue diagnosticado de síndrome neuroléptico maligno. El paciente recibió tratamiento con bromocriptina y diazepam durante hospitalización y tuvo evolución favorable de síntomas neuropsiquiátricos. El síndrome neuroléptico maligno es un evento adverso raro y fatal. Está asociado al uso de psicotrópicos, especialmente antipsicóticos.

We describe the clinical presentation and diagnostic difficulties of a case of Neuroleptic Malignant Syndrome in a general hospital. The patient was an 18-year-old male with severe mental retardation and a history of seizures who received irregular treatment with risperidone and phenytoin. After presenting irritability, aggressiveness, and psychomotor agitation, he went to a psychiatric hospital where received an increase in the dose of risperidone. Subsequently, due to persistence of aggressiveness, he went to a psychiatric hospital where haloperidol, midazolam and levomepromazine were indicated, after few days developed oromandibular dystonia, temperature rise and generalized dystonia with difficulty swallowing food, which is why he went to hospital general and was diagnosed with Neuroleptic Malignant Syndrome. Patient received treatment with bromocriptine and diazepam during hospitalization with favorable evolution of neuropsychiatric symptoms. Neuroleptic Malignant Syndrome is a rare and fatal adverse event. It is associated with the use of psychotropics, especially antipsychotics.

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Neuroleptic malignant syndrome is a rare and potentially fatal clinical condition frequently associated with the use of antipsychotics. In the literature, there is only one case report associated with the intake of organophosphates. We present the case of a patient who presented with a clinical picture compatible with neuroleptic malignant syndrome, after the ingestion of an organophosphate (chlorpyrifos). A 57-year-old man who consulted for attempted suicide, acute deterioration of consciousness, torpid neurological evolution, and associated autonomic instability associated with rigidity, persistent hyperthermia, and elevated CPK. Bromocriptine treatment was offered, which resolved the clinical picture. The association with the ingestion of an organophosphate was established, and he was discharged without sequelae. The diagnosis of neuroleptic malignant syndrome is clinical and should be considered in any case of exposure to substances that may lead to dysregulation of dopaminergic neurotransmission in order to initiate timely therapy and impact outcomes.

El síndrome neuroléptico maligno es una condición clínica rara y potencialmente letal que frecuentemente se asocia con el uso de antipsicóticos. En la literatura especializada se encontró únicamente un reporte de caso relacionado con la ingestión de organofosforados. Se presenta un paciente con un cuadro clínico correspondiente al síndrome neuroléptico maligno posterior a la ingestión de clorpirifós. Como resultado de un intento de suicidio con el mencionado organofosforado, el hombre de 57 años presentó deterioro agudo del estado de consciencia, evolución neurológica tórpida e inestabilidad autonómica asociada a rigidez e hipertermia persistentes, así como incremento de la creatina-fosfocinasa (creatine phosphokinase, CPK). Se le administró tratamiento con bromocriptina, con lo cual el cuadro clínico remitió, y fue dado de alta sin secuelas. El diagnóstico del síndrome neuroléptico maligno es clínico y debe contemplarse en cualquier caso de exposición a sustancias que puedan resultar en una desregulación de la neurotransmisión dopaminérgica, con el fin de iniciar el tratamiento oportuno y contrarrestar efectivamente los efectos.

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Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis presents commonly with psychiatric symptoms. One cohort of these patients reported that antipsychotic administration led to neuroleptic intolerance (NI) in 19% of them, which was preventable by a prompt encephalitis diagnosis. To date, there is no clear description of the "neuroleptic intolerance" spectrum in general or during anti-NMDAR encephalitis. We aimed to synthesize epidemiological and clinical characteristics of patients with NI and confirmed anti-NMDAR encephalitis, the time to the encephalitis diagnosis, the disease course, outcomes at discharge, and associated factors. We systematically searched three databases, to include clinical cases, case series, and observational studies. Additionally, we reported one clinical case. Results were summarized using narrative synthesis and the quality of the included studies was assessed. We included 22 records representing 40 patients (28 females; mean age, 24.6). Overall, the evidence quality was low. Initially, most cases were admitted in psychiatric wards (70%) with purely psychiatric symptoms (37.5%). However, most of them developed subtle concomitant neurological symptoms. The mean time to anti-NMDAR encephalitis diagnosis was 26.7 days, which was triggered by the NI in six patients. We found no association between clinical variables as delayed diagnosis, admission to psychiatric wards or the presence of malignancy with outcome variables as unfavorable outcomes at discharge, ICU, or mechanical ventilation requirement. A thorough neurological examination in young patients with new-onset psychiatric symptoms could help emergency physicians, neurologists, and psychiatrists suspect anti-NMDAR encephalitis earlier. Awareness of NI as a potential side effect during suspected or confirmed anti-NMDAR encephalitis is encouraged.

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El síndrome neuroléptico maligno es una condición clínica rara y potencialmente letal que frecuentemente se asocia con el uso de antipsicóticos. En la literatura especializada se encontró únicamente un reporte de caso relacionado con la ingestión de organofosforados. Se presenta un paciente con un cuadro clínico correspondiente al síndrome neuroléptico maligno posterior a la ingestión de clorpirifós. Como resultado de un intento de suicidio con el mencionado organofosforado, el hombre de 57 años presentó deterioro agudo del estado de consciencia, evolución neurológica tórpida e inestabilidad autonómica asociada a rigidez e hipertermia persistentes, así como incremento de la creatina-fosfocinasa (creatine phosphokinase, CPK). Se le administró tratamiento con bromocriptina, con lo cual el cuadro clínico remitió, y fue dado de alta sin secuelas. El diagnóstico del síndrome neuroléptico maligno es clínico y debe contemplarse en cualquier caso de exposición a sustancias que puedan resultar en una desregulación de la neurotransmisión dopaminérgica, con el fin de iniciar el tratamiento oportuno y contrarrestar efectivamente los efectos.

Neuroleptic malignant syndrome is a rare and potentially fatal clinical condition frequently associated with the use of antipsychotics. In the literature, there is only one case report associated with the intake of organophosphates. We present the case of a patient who presented with a clinical picture compatible with neuroleptic malignant syndrome, after the ingestion of an organophosphate (chlorpyrifos). A 57-year-old man who consulted for attempted suicide, acute deterioration of consciousness, torpid neurological evolution, and associated autonomic instability associated with rigidity, persistent hyperthermia, and elevated CPK. Bromocriptine treatment was offered, which resolved the clinical picture. The association with the ingestion of an organophosphate was established, and he was discharged without sequelae. The diagnosis of neuroleptic malignant syndrome is clinical and should be considered in any case of exposure to substances that may lead to dysregulation of dopaminergic neurotransmission in order to initiate timely therapy and impact outcomes.

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INTRODUCTION: Neuroleptic malignant syndrome (NMS) is uncommon, with an incidence of 0.01% to 3.23%, and is associated with the use of drugs that intervene with dopamine, causing hyperthermia, muscular rigidity, confusion, autonomic instability and death. CASE REPORT: A 35-year-old man with a history of catatonia, refractory epilepsy and functional impairment, required frequent changes in his anticonvulsant and antipsychotic treatment, due to adverse effects. During 2019, in the month of July, clozapine was changed to amisulpride, in September he developed fever, muscle stiffness, stupor, diaphoresis and tachypnea over a two-week period; paraclinical tests showed elevated creatine phosphokinase (CPK) and leukocytosis, so NMS was considered. The antipsychotic was withdrawn and he was treated with bromocriptine and biperiden, with a good response. Ten days after discharge, he began treatment with olanzapine, which generated a similar episode to the one described in December, with subsequent management and resolution. DISCUSSION: The diagnosis is based on the use of drugs that alter dopamine levels, plus altered state of consciousness, fever, autonomic instability and paraclinical tests showing leukocytosis and elevated CPK. Differential diagnosis must be ruled out. Early diagnosis generally leads to total remission, although some patients will suffer complications, long-term sequelae or recurrences. The recurrence in this case derived from the early reintroduction of the neuroleptic after the first episode. Treatment should be individualised according to severity to avoid mortality. CONCLUSIONS: Atypical antipsychotics are rarely suspected of generating NMS. Moreover, the time to reintroduction after an episode must also be taken into account.

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RESUMEN Fundamento: los neurolépticos con efecto antipsicótico, son eficaces para controlar los síntomas de la esquizofrenia, delirios y alucinaciones. El síndrome neuroléptico maligno es el efecto adverso más grave ocasionado por los antipsicóticos. Objetivo: presentar un caso inusual de un paciente con diagnóstico de cuadro psicótico que presentó un síndrome neuroléptico maligno ocasionado por los antipsicóticos. Presentación del caso: se ingresa un paciente que escucha voces dentro de su cabeza y el médico lo nota hiperconcentrado además realizaba movimientos estereotipados con dificultades para deambular. Al septimo día de hospitalización comienza con rigidez generalizada, temblor, trastornos del lenguaje y disfagia que se interpreta como un síndrome extrapiramidal de causa medicamentosa, con cifras de creatininfosfoquinasa aumentadas. Se emplea la bromocriptina 2,5 mg cada 12 horas, además de hidratación enérgica, anticoagulación profiláctica con heparina de bajo peso molecular y evaluación periódica de la función respiratoria y renal. Conclusiones: el síndrome neurológico maligno corresponde a una reacción de tipo idiosincrático, producida por cualquier fármaco bloqueador del receptor de la dopamina asociada clásicamente a los fármacos antipsicóticos de alta potencia como haloperidol y flufenazina, como se observó en el caso, por lo que fue necesario identificar los signos prodrómicos de forma precoz y realizar las modificaciones terapéuticas de forma oportuna a fin de prevenir el cuadro grave y restablecer la salud del enfermo con mínimo riesgo.

ABSTRACT Background: neuroleptics with an antipsychotic effect are effective in controlling the symptoms of schizophrenia, delusions and hallucinations. Neuroleptic malignant syndrome is the most serious adverse effect caused by antipsychotics. Objective: to present an unusual case of a patient with a diagnosis of psychotic symptoms who presented a neuroleptic malignant syndrome caused by antipsychotics. Case report: a patient who listens to voices inside his head is admitted and the doctor notes that he was hyperconcentrated and performed stereotyped movements with difficulties in wandering. At the 7th day of hospitalization he begins with generalized rigidity, tremor, language disorders and dysphagia that is interpreted as an extrapyramidal syndrome of drug cause, with increased creatinine phosphokinase (CK) levels. Bromocriptine 2.5 mg every 12 hours is used, in addition to vigorous hydration, prophylactic anticoagulation with low molecular weight heparin and periodic assessment of respiratory and renal function. Conclusions: the malignant neurological syndrome corresponds to an idiosyncratic reaction, produced by any dopamine receptor blocker drug classically associated with high potency antipsychotic drugs such as haloperidol and fluphenazine, as observed in the case presented in the article, so it was necessary to identify the prodromal signs early and make the therapeutic changes in a timely manner in order to prevent the serious condition and restore the health of the patient with minimal risk.

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La risperidona es un antagonista selectivo monoaminérgico, con una elevada afinidad por receptores dopaminérgicos, que puede producir síndrome neuroléptico maligno (SNM), considerado una emergencia médica con alto riesgo de muerte. Tiene una incidencia de hasta el 3% y su mortalidad está entre el 10 y 20%. Se reporta el caso de una paciente de 56 años, que reunía los criterios clínicos del SNM, inducido por el uso de risperidona y facilitado por una sepsis de origen urinario. El tratamiento se condujo con un agente agonista dopaminérgico y cambio del antipsicótico, procedimientos que resultaron en una adecuada evolución clínica. El SNM es una entidad de baja prevalencia, para la cual existen criterios diagnósticos con especificidad y sensibilidad mayor del 90%, por lo que debe diferenciarse claramente de otras patologías. Se discute el mecanismo mediante el cual la infección urinaria facilitaría la ocurrencia de esta enfermedad. El diagnóstico precoz mejora la respuesta al manejo adecuado que se establezca en cada caso.

Risperidone is a selective monoaminergic antagonist with a high affinity for dopamine receptors that can cause neuroleptic malignant syndrome (NMS), considered a life-threatening medical emergency. It has an incidence of up to 3% and its mortality is between 10 and 20%. The case of a 56-year-old female who met the clinical criteria of NMS, induced by the use of risperidone and facilitated by a sepsis of urinary origin, is reported. It was managed with a dopamine agonist and the change of antipsychotic, which resulted in a favorable clinical course. The NMS is a low-prevalence entity whose diagnosis has specificity and sensitivity greater than 90%, reason for which must be clearly differentiated from other pathologies. The mechanism by which urinary infection could facilitate the occurrence of this disease is discussed. Early diagnosis improves the response to an adequate management to be established in each case.

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El síndrome neuroléptico maligno es una rara y potencialmente fatal reacción adversa medicamentosa, asociada usualmente al uso de antipsicóticos. Tiene por características la presencia de fiebre, rigidez muscular, estado mental alterado y disfunción autonómica. Los hallazgos de laboratorio son inespecíficos, sin embargo, la presencia de leucocitosis y elevación de la creatina fosfoquinasason hallazgos frecuentes. Presentamos el caso de un paciente varón de 51 años, natural de Lima con antecedentes médicos de tuberculosis pulmonar y esquizofrenia que acude a nuestro hospital con un cuadro de psicosis quien, luego de ser tratado con ziprasidona administrada por vía intramuscular, presentó los síntomas característicos de un síndrome neuroléptico maligno. Conocer la clínica y la fisiopatología de este síndrome nos permitirá un mejor abordaje, ya que por su poca frecuencia podría no llegar a plantearse dentro de los diagnósticos diferenciales, lo que resultaría perjudicial para el paciente.

Neuroleptic malignant syndrome is a rare and potentially fatal drug adverse reaction, usually associated with antipsychotics. Signs and symptoms include: fever, muscle rigidity, altered mental status and autonomic dysfunction. Laboratory findings are nonspecific, however the presence of leukocytosis and elevated creatinine phosphokinase are frequent findings. We present the case of a 51-year-old male patient from Lima with a medical history of pulmonary tuberculosis and schizophrenia that comes to our hospital with psychotic symptoms. After being treated with ziprasidone, administered by intramuscular injection presents with typical symptoms of neuroleptic malignant syndrome. Knowing the clinical features and the pathophysiology of this syndrome will allow us to better approach the condition. Due to its infrequent presentation, it may not be considered within the differential diagnosis, which could be harmful to the patient.

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RESUMEN El síndrome neuroléptico maligno (SNM) es una complicación severa de los antipsicóticos, en especial los de primera generación como el haloperidol, que fue el primero en el que se describió esta patología, caracterizada por fiebre, rigidez, alteración del estado de conciencia y disautonomías. Por otro lado, la mielinólisis central pontina (ahora llamada síndrome de desmielinización osmótica) resulta de las alteraciones agudas séricas del sodio, como las que ocurren en las reposiciones de hiponatremia, y podría poner en riesgo la vida al igual que el SNM. La asociación de estas dos patologías es inusual y hasta el momento no se conoce con claridad su relación causal, producto de los pocos casos reportados. Aunque se conoce la mortalidad del síndrome neuroléptico maligno, la compañía de la mielinolisis central pontina podría aumentar la morbimortalidad de esta entidad, por lo cual es necesario reconocerla rápidamente para prevenir la aparición de complicaciones, ya que no cuenta con un tratamiento específico. Presentamos el caso de un paciente joven que cursó con estas dos patologías, y consideramos que la causa de la mielinolisis central pontina fue el haloperidol, así como del SNM. A pesar de ello, este medicamento continúa siendo muy seguro en la práctica clínica ya que la aparición de estas complicaciones es una reacción idiosincrática por algún tipo de susceptibilidad genética desconocida.

SUMMARY Neuroleptic malignant syndrome (NMS) is a severe complication of antipsychotics, especially those of first generation such as haloperidol, which was the first in which this pathology was described, characterized by: fever, rigidity, alteration of the state of consciousness and dysautonomies. On the other side, central pontine myelinolysis (Now Called Osmotic Demyelination Syndrome), search results of acute sodium alterations of sodium, as those occurring in hyponatremia replenings and could put life at risk just like the NMS. The association of these two pathologies is unusual and until now, their causal relationship, the result of the few cases reported, is not clearly known. Although the relationship of the neurological syndrome may be limited, the company of central myelolysis could increase the morbidity of this entity, so it is necessary to be required quickly to prevent the onset of complications, which does not have a specific treatment. We present the case of a young patient who has these pathologies and we consider that the cause of centralized myelinolysis is haloperidol as well as NMS, despite this, this medication continues to be very safe in clinical practice since the appearance of These complications is an idiosyncratic reaction due to some type of unknown genetic susceptibility.

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RESUMEN El síndrome neuroléptico maligno like o crisis acinética es una rara y potencialmente letal complicación del abandono de medicación de los pacientes con enfermedad de Parkinson. Se presenta el caso clínico de un paciente de sexo masculino de 52 años de edad, con antecedente de enfermedad de Parkinson de 10 años de evolución que se encuentra en tratamiento con levodopa-carbidopa. Acude a consultar por disminución del estado de conciencia y rigidez muscular generalizada, relacionado con el abandono de medicación 7 días antes del inicio de los síntomas.

ABSTRACT Neuroleptic malignant-like syndrome or akinetic crisis is a rare and potentially lethal complication of the withdrawal of medication of patients with Parkinson's disease. We present the clinical case of 52-year man with 10-year history of Parkinson's disease who is being treated with levodopa-carbidopa. He consults for decreased level of consciousness and general muscular rigidity, related to the withdrawal of the medication 7 days before the onset of symptoms.

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Objective To describe the case of a patient with schizophrenia on clozapine treatment who had an episode of heat stroke. Case description During a heat wave in January and February 2014, a patient with schizophrenia who was on treatment with clozapine was initially referred for differential diagnose between systemic infection and neuroleptic malignant syndrome, but was finally diagnosed with heat stroke and treated with control of body temperature and hydration. Comments This report aims to alert clinicians take this condition into consideration among other differential diagnoses, especially nowadays with the rise in global temperatures, and to highlight the need for accurate diagnosis of clinical events during pharmacological intervention, in order to improve treatment decisions and outcomes.

Objetivo Descrever o caso de um paciente com esquizofrenia em tratamento com clozapina acometido por um episódio de heat stroke. Descrição do caso Durante uma onda de calor em janeiro e fevereiro de 2014, um paciente com esquizofrenia em tratamento com clozapina foi inicialmente encaminhado para diagnóstico diferencial de infecção sistêmica e síndrome neuroléptica maligna, tendo obtido o diagnóstico final de heat stroke, tratado com controle de temperatura corporal e hidratação. Comentários Este relato de caso tem como objetivo alertar os clínicos para este diagnóstico diferencial, que pode surgir com mais frequência à medida que as temperaturas globais continuarem a aumentar, e também destacar a importância da realização de um diagnóstico mais acurado, que possa melhorar as decisões de tratamento e os desfechos clínicos para os pacientes.

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OBJETIVOS E JUSTIFICATIVA: Identificar e caracterizar as interações medicamentosas presentes em prescrições médicas da Unidade de Terapia Intensiva (UTI) de um hospital público da cidade de Feira de Santana, Bahia. Uma vez que Interações medicamentosas (IM) representam fontes potencialmente remediáveis de erros na assistência e um risco para os pacientes. MÉTODOS: O estudo realizado foi do tipo descritivo. Após aprovação do Comitê de Ética em Pesquisa foram coletadas aleatoriamente 28 prescrições médicas da Unidade de Terapia Intensiva do hospital no ano de 2013, sendo necessário o preenchimento de uma ficha de coleta previamente estabelecida. Os dados coletados foram analisados pelo programa Micromedex® Drug Interactions, este caracterizou as interações medicamentosas segundo a gravidade e documentação comprobatória. RESULTADOS: Das 28 prescrições analisadas, 2 apresentaram nenhuma interação medicamentosa, enquanto 26 apresentaram alguma interações medicamentosas, resultando 99 potenciais interações medicamentosas, sendo os fármacos mais envolvidos: Midazolam, Ácido Acetilsalicílico, Fentanil e Dipirona. Interações medicamentoas mais frequentes foram: Fentanil + Mi­ dazolam; Dipirona + Enoxaparina; Midazolam + Omeprazol; Ácido Acetilsalicílico + Insulina Humana Regular. Segundo a gravidade foram encontradas: 5 contra Indicado, 31 maior, 58 moderado e 5 menor. 29 interações medicamentosas possuíam documentação excelente, 39 boa, 31 razoável e nenhuma com documentação desconhecida O uso, simultâneo de Fentanil + Midazolam pode resultar em depressão respiratória aditiva. Já o uso de Metoclopramida + Haloperidol pode aumentar o risco de reações extrapiramidais ou síndrome maligna dos neurolépticos. CONCLUSÃO: Confirmou­se que as interações medicamentosas são um problema frequente e cada vez mais relevante, pois identificá­las tornou­se um desafio para os profissionais de saúde...

BACKGROUND AND OBJECTIVE: To identify and characterize the Drug Interaction present in prescriptions of Intensive Care Unit (ICU) of a public hospital in the city of Feira de Santana, Bahia. Since, Drug Interaction (DI) represent potentially remediable sources of errors in care and a risk to patients. METHODS: The study was observational in nature. After approval by the Research Ethics Committee were randomly collected from 28 medical prescriptions in the Intensive Care Unit of the hospital in 2013, completing a previously established data collection form is required. The collected data were analyzed by ® Drug Interactions, Micromedex this program characterized the drug interaction according to the severity and supporting documentation. RESULTS: Of the 28 prescriptions analyzed, 2 showed no drug interaction, while 26 showed some drug interaction, resulting in 99 potential drug interactions being the drugs most involved: Midazolam, Acetylsalicylic Acid, Fentanyl and Dipyrone. Frequently drugs interactions were: Midazolam + Fentanyl; Dipyrone + Enoxaparin, Midazolam + Omeprazole, Acetylsalicylic Acid + Regular Human Insulin. According to severity were found: 5 against Indicated, 31 largest, 58 moderate and 5 smaller. 29 drug interaction had excellent documentation, 39 good, 31 fair, and none with unknown Using documentation, simultaneous Midazolam + Fentanyl may result in additive respiratory depression. Already using Metoclopramide + Haloperidol may increase the risk of extrapyramidal reactions or neuroleptic malignant syndrome. CONCLUSION: It was confirmed that the drug interaction is a frequent problem and increasingly relevant because identifying it became a challenge for health professionals...

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