Ziprasidone Associated Neuroleptic Malignant Syndrome

Abstract

INTRODUCTION Neuroleptic malignant syndrome (NMS) is a severe and potentially lethal disorder due to an adverse reaction to dopamine receptor antagonism or the rapid withdrawal of dopaminergic medications.1 While incidence is estimated to be 0.02%1 generally and 0.2%2 among neuroleptic users, NMS continues to be an unpredictable and potentially life-threatening condition of which case reports continue to be a main source of information for clinicians.3 Despite the advent of second-generation antipsychotics (SGA), NMS continues to be a rare yet severe adverse reaction to neuroleptics.4 It is seen most often with abrupt cessation, decrease, or increase in dopaminergic dose.5 A recent systematic literature review conducted by Murri et al.5 found only 186 individual cases meeting their criteria for SGA-NMS, only six of which were caused by ziprasidone. Our patient met the Diagnostic and Statistical Manual of Mental Disorders, Revised Fifth Edition,6 (DSM-V) diagnostic criteria for NMS as she presented with hyperthermia, profuse diaphoresis, generalized muscle rigidity, elevated creatinine phosphokinase, delirium, and autonomic instability. All were associated with exposure to a dopamine receptor antagonist, in this case, ziprasidone. While most patients fully recover and mortality rates have been decreasing due to early recognition and treatment, fatality rates are estimated between 5 10%.1-3 This case demonstrated how NMS can present as a mimic of sepsis or serotonin syndrome.