ECT for NMS-Case Report from Portugal
Out on PubMed, from clinicians in Lisbon, Portugal, is this case report:
Diagnosis and Treatment of Neuroleptic Malignant Syndrome in the Intensive Care Unit: A Case Report.
Acta Med Port. 2020 Sep 30. doi: 10.20344/amp.13019. Online ahead of print.PMID: 32997617
From the text:
CASE REPORT A 66-year-old man with prior diagnosis of schizophrenia was admitted to an ICU due to respiratory infection and septic shock syndrome, evolving rapidly to stupor and respiratory failure, and requiring sustained sedation for orotracheal intubation. At admission, all psychiatric medication was discontinued, and a course of empirical antibiotic treatment was started. Three days later, upon improvement of respiratory function and laboratory parameters, propofol was interrupted and the patient was extubated. However, leukocytosis and mild elevations of lactate dehydrogenase and liver transaminases persisted, despite normal creatine kinase levels. In the following days, generalized tremor and marked rigidity was noted, and the patient developed sustained autonomic nervous dysfunction, with tachycardia (up to 117 bpm), unstable blood pressure (systolic: 130 - 163 mmHg; diastolic: 67 - 82 mmHg), diaphoresis, fever (up to 38.6º C) and diarrhea. Rapid deterioration of respiratory function with accumulation of respiratory secretions and ineffective cough reflex led to re-intubation and prompted a new course of empirical antibiotic treatment. Despite full resolution of the respiratory infection, motor and autonomic abnormalities persisted and weaning of invasive ventilation proved impossible, prompting a liaison consultation with both Neurology and Psychiatry. Psychiatric assessment, review of medical records and family interview revealed that he had been diagnosed with schizophrenia at the age of 40 but had never complied with treatment. However, five months prior to the current episode, the patient had been admitted to a psychiatric inpatient unit and had started, for the first time, continued treatment with haloperidol (15 mg/day), clozapine (100 mg/day) and flurazepam (15 mg/day). Except for childhood epilepsy, with no known manifestations or treatment since adolescence, medical history was unremarkable, as was family neuropsychiatric history. On examination, the patient was mostly uncooperative, responding only occasionally with yes-no answers using eye-blinks or finger movements. Waxy flexibility and catatonic posturing were noted (Video 1). Brain CT and MRI, EEG, cerebral-spinal fluid examination and cultures were unremarkable, and catatonia due to a medical condition, or NMS, were considered. Formal assessment revealed a Bush-Francis Catatonia Rating Scale (BFCRS) score of 23, making it impossible to perform other clinical assessments, including the Montreal Cognitive Assessment Scale (MoCA). Since all neuroleptics had been interrupted previously, and supportive measures were fully in place, treatment was started with lorazepam (2.5 to 5 mg/day), with no clear benefit. At this moment, ECT was offered and accepted by the patient and family. A course of twice weekly, bitemporal, brief-pulse ECT was thus started on day 26 after admission, under propofol (50 to 120 mg/session) and succinylcholine (50 to 75 mg/session). After four sessions, the patient had improved sufficiently to be extubated (Video 2), and after 11 treatments, given the stability of clinical response, with a 65,2% reduction in the BFRCS (score = 8), ECT was interrupted. Bromocriptine was then started and titrated to 15 mg/day, resulting in further improvement, with most catatonic symptoms subsiding (BFCRS score = 1) and a MoCA score of 11 (Video 3).
This is a report of a desperately ill patient with NMS who recovered with ECT. While it adds nothing particularly new, it is a reminder of the potential downside to neuroleptics and the need to consider ECT as soon as possible in the course of serious cases. Our Portuguese colleagues are to be commended for the sophisticated medical/psychiatric management of their patient.
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