Neuroleptic Malignant-Like Syndrome Associated with Carbamazepine and Fluoxetine: A Pediatric Case Report
Article Sidebar
How to Cite
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Downloads
Societal impact
Main Article Content
Abstract
Malignant Neuroleptic Syndrome (MNS) is a severe, potentially life‑threatening adverse reaction, classically associated with the use of antipsychotics. Its occurrence in the pediatric population is rare, and the literature on atypical, non‑neuroleptic causal agents is limited. We present a case of malignant neuroleptic syndrome‑like reaction in a pediatric patient exposed to carbamazepine and fluoxetine, highlighting the challenges in differential diagnosis and clinical management. The patient was an 11‑year‑old male with neurological sequelae, who developed a clinical picture characterized by high fever, severe muscle rigidity, autonomic instability, and altered consciousness following treatment with carbamazepine and fluoxetine. The diagnosis was established based on clinical criteria and exclusion of other etiologies. The suspected drugs were discontinued, and intensive supportive treatment was initiated, including benzodiazepines and a dopaminergic agonist (bromocriptine), leading to progressive clinical improvement. This case underscores the importance of considering MNS in the differential diagnosis of hyperthermic emergencies in pediatrics, even in the absence of exposure to typical antipsychotics. A high index of suspicion is crucial for timely diagnosis and treatment, which is decisive in reducing the morbidity and mortality associated with this entity.
Article Details
References
1. Horseman M, Panahi L, Udeani G, Tenpas AS, Verduzco R Jr, Patel PH, et al. Drug-Induced Hyperthermia Review. Cureus. 2022;14(7):e27278.
2. Caroff SN, Watson CB, Rosenberg H. Drug-induced Hyperthermic Syndromes in Psychiatry. Clin Psychopharmacol Neurosci. 2021;19(1):1-11.
3. Hakeem H, Nasir M, Khan MF, Syed NM, Rajput HM, Ahmed A, et al. Recognizing Movement Disorder Emergencies - A Practical Review For Non-Neurologist. J Ayub Med Coll Abbottabad. 2019;31(3):448-53.
4. Kuhlwilm L, Schönfeldt-Lecuona C, Gahr M, Connemann BJ, Keller F, Sartorius A. The neuroleptic malignant syndrome-a systematic case series analysis focusing on therapy regimes and outcome. Acta Psychiatr Scand. 2020;142(3):233-41.
5. Ghaziuddin N, Hendriks M, Patel P, Wachtel LE, Dhossche DM. Neuroleptic Malignant Syndrome/Malignant Catatonia in Child Psychiatry: Literature Review and a Case Series. J Child Adolesc Psychopharmacol. 2017;27(4):359-65.
6. Komatsu T, Nomura T, Takami H, Sakamoto S, Mizuno K, Sekii H, et al. Catatonic Symptoms Appearing before Autonomic Symptoms Help Distinguish Neuroleptic Malignant Syndrome from Malignant Catatonia. Intern Med. 2016;55(19):2893-7.
7. Delay J, Deniker P. Drug-induced extrapyramidal syndromes: diseases of the basal Ganglia. En: Vinken PJ, Bruyn GW, editores. Handbook of Clinical Neurology. Amsterdam: North-Holland Publishing Co; 1968. p. 248–66.
8. Oruch R, Pryme IF, Engelsen BA, Lund A. Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatr Dis Treat. 2017;13:161-75.
9. Velamoor VR, Norman RM, Caroff SN, Mann SC, Sullivan KA, Antelo RE. Progression of symptoms in neuroleptic malignant syndrome. J Nerv Ment Dis. 1994;182(3):168-73.
10. Dosi R, Ambaliya A, Joshi H, Patell R. Serotonin syndrome versus neuroleptic malignant syndrome: a challenging clinical quandary. BMJ Case Rep. 2014;2014:bcr2014204154.
11. León-Amenero D, Huarcaya-Victoria J. Neuroleptic malignant syndrome in children and adolescents: Systematic review of case reports. Rev Colomb Psiquiatr (Engl Ed). 2021;50(4):290-300.
12. Singhai K, Kuppili PP, Nebhinani N. Atypical neuroleptic malignant syndrome: A systematic review of case reports. Gen Hosp Psychiatry. 2019;60:12-9.
13. Paul G, Singhal S, Paul BS, Singh G, Goyal S. Widening spectrum of neuroleptic malignant syndrome: Case series. J Anaesthesiol Clin Pharmacol. 2022;38(2):309-14.
14. Nisijima K, Kusakabe Y, Ohtuka K, Ishiguro T. Addition of carbamazepine to long-term treatment with neuroleptics may induce neuroleptic malignant syndrome. Biol Psychiatry. 1998;44(9):930-1.
15. O'Griofa FM, Voris JC. Neuroleptic malignant syndrome associated with carbamazepine. South Med J. 1991;84(11):1378-80.
16. Bassi V, Fattoruso O, Santinelli C. A rare iatrogenic association of syndrome of inappropriate secretion of antidiuretic hormone, neuroleptic malignant syndrome and rhabdomyolysis. Oxf Med Case Reports. 2019;2019(3):omz010.
17. Halman M, Goldbloom DS. Fluoxetine and neuroleptic malignant syndrome. Biol Psychiatry. 1990;28(6):518-21.
18. Hu T, Hall E. A case of neuroleptic malignant syndrome with aripiprazole and fluoxetine. CJEM. 2018;21(2):299-301.
19. Mazhar F, Akram S, Haider N, Ahmed R. Overlapping of Serotonin Syndrome with Neuroleptic Malignant Syndrome due to Linezolid-Fluoxetine and Olanzapine-Metoclopramide Interactions: A Case Report of Two Serious Adverse Drug Effects Caused by Medication Reconciliation Failure on Hospital Admission. Case Rep Med. 2016;2016:7128909.
20. Schünemann H, Hill S, Guyatt G, Akl EA, Ahmed F. The GRADE approach and Bradford Hill's criteria for causation. J Epidemiol Community Health. 2011;65(5):392-5.