Malignant Neuroleptic Syndrome: Causes, Symptoms & Treatment

Malignant neuroleptic syndrome (abbreviated as MNS) is also known as malignant neuroleptic syndrome. This is a rare side effect that results from taking neuroleptics.

What is malignant neuroleptic syndrome?

Neuroleptic syndrome is a rare but life-threatening condition caused by dopamine antagonists (especially neuroleptics), but equally by lithium or antidepressants. It usually occurs with a high dosage of the drugs or a rapid increase in the dose in the first four weeks after the start of therapy or the change of drugs. Neuroleptic syndrome is reported to occur in about 0.2 percent of patients treated with neuroleptics. The clinical picture could be observed most frequently when taking haloperidol, but in principle also with all other neuroleptics. In addition, individual familial cases are known, so that a genetic component cannot be excluded with regard to the development of the disease. Malignant neuroleptic syndrome represents a feared emergency in psychiatry, because the clinical picture progresses rapidly and can also rapidly trigger life-threatening complications.

Causes

Drugs that are possible triggers for malignant neuroleptic syndrome include:

Other risk factors such as the use of strong antipsychotic neuroleptics and a high dosage the can promote a malignant neuroleptic syndrome. Pre-existing brain damage and thyroid disease can also influence the development of a malignant neuroleptic syndrome. This is also true in the presence of physical exhaustion, fluid deficiency, or hyponatremia.

Symptoms, complaints, and signs

Malignant neuroleptic syndrome causes various symptoms, such as extrapyramidal motor disturbances, extreme muscle stiffness, or gaze spasms. Affected individuals sweat profusely, and sweating sometimes occurs; tachycardia and tachypnea occur. Heart palpitations, rapid breathing and changes in blood pressure, urinary or fecal incontinence have also been observed in such a case. Furthermore, speech and swallowing disorders, increased salivation and an increase in body temperature may occur. Confusion, impaired consciousness, and even coma occur in association with malignant neuroleptic syndrome. In most cases, malignant neuroleptic syndrome begins within less than ten days after starting therapy with the drug that is the trigger. Rarely, this can take up to two months. Within two days, but in some cases within a few hours, malignant neuroleptic syndrome usually develops into full-blown symptoms.

Diagnosis and course of the disease

To make the diagnosis that malignant neuroleptic syndrome is present, general measures are first taken, such as measuring fever and blood pressure. The latter can be either high or low, but is also often labile. Other signs usually include a CPK increase, but may also be mild, elevated LDH (lactate dehydrogenase), leukocytosis, proteinuria, and myoglobinuria. In addition, hyponatremia and hypernatremia, mild protein elevation in CSF, low serum iron, serum calcium, and magnesium are present. Diagnosis and treatment as early as possible are very important to avoid sequelae. A serious complication that can cause malignant neuroleptic syndrome is rhabdomyolysis with myoglobinuria. This can lead to acute renal failure. Other risks include hyperthermia, which may cause dehydration, which in turn may cause phlebothrombosis as well as pulmonary embolism. In addition, seizures are possible.In the worst case, malignant neuroleptic syndrome can lead to multiple organ failure. The clouding and especially the muscle rigidity and fever can increase rapidly and very quickly lead to life-threatening decompensation. Therefore, treatment is essential.

Complications

In neuroleptic syndrome, many different complaints usually occur. However, they do not always point directly to the syndrome, so that in many cases there is a delay in treatment. As a rule, those affected suffer from a strong increase in perspiration and also from heavy sweating. These can significantly limit and reduce the quality of life. Similarly, neuroleptic syndrome not infrequently results in palpitations, which in the worst case can lead to a heart attack. Sufferers suffer from fecal incontinence, which not infrequently leads to depression and other psychological upsets. Sufferers also continue to suffer from fever and, without treatment of the disease, often from renal insufficiency. This can lead to death and the affected person is then dependent on dialysis or a donor kidney. Treatment of neuroleptic syndrome is relatively simple and quick with the help of medication and by increasing the intake of fluids. Complications do not occur and symptoms can be resolved relatively well. Usually, if treated early, neuroleptic syndrome also does not reduce the patient’s life expectancy.

When should you see a doctor?

People who are under the influence of a drug from the series of neuroleptics should consult a doctor if there are negative changes in their health condition. If there are disturbances in motor function or heart rhythm, medical clarification of the symptoms is required. If there is palpitations, increased blood pressure, sweating, increased oxygen demand, or other vegetative irregularities, a physician should be consulted. If breathing is difficult or the affected person suffers from accelerated breathing, a doctor should be consulted. If communication problems occur, there is also cause for concern. If speech or swallowing difficulties occur, a doctor should be consulted. A dry mouth and throat, an interruption in the regular natural flow of saliva, and an elevated body temperature are signs of an existing irregularity. A visit to a doctor is necessary so that optimization of the developed treatment plan for therapy of the underlying disease can take place. If there is an irregularity of the digestive tract, incontinence or problems with going to the toilet, a doctor should be consulted. If the patient shows mental confusion or disorders of consciousness set in, a physician must be informed of the observations, as these are important warning signs of the organism. If there is a loss of consciousness, an ambulance should be alerted. The affected person requires first aid care from persons present until the arrival of the emergency medical technician.

Treatment and therapy

The primary action if malignant neuroleptic syndrome has been identified is to immediately discontinue the causative neuroleptic or triggering antipsychotic. All other measures serve more as support and relate primarily to ensuring important vital functions. These include ventilation, rehydration, and prevention of further complications, if necessary. Fluid and electrolyte loss must be compensated for, and fever must be brought down as quickly as possible with medication. Sometimes, in difficult cases, temporary dialysis may be required. Muscle relaxants and dopamine agonists are also effective support. Other measures include monitoring such as ECG, volume substitution, and thromboprophylaxis. In severe cases or if there is no improvement after 24 hours, dantrolene is used. This is the case with increased muscle tension leading to severe muscle spasms. Due to the fact that malignant neuroleptic syndrome is a life-threatening condition, it is treated in the intensive care unit.

Outlook and prognosis

Without prompt medical care, the prognosis of this syndrome is unfavorable. A life-threatening condition is present, and action must be taken as soon as possible. Otherwise, premature death of the affected individual will occur.The trigger of the disease is a side effect of medically prescribed medical preparations for the therapy of an existing primary disease. For this reason, relief of the additional complaints can be achieved if cooperation is sought with the attending physician. As soon as the first health impairments appear, the physician treating the primary disease should be consulted. A change in the developed treatment plan is necessary so that the malignant neuroleptic syndrome regresses and can be fully treated. Through the administration of alternative medications, there is an alleviation of the health irregularities that have occurred. The undesirable side effects gradually disappear if acted upon as soon as possible. Otherwise, in addition to the development of a life-threatening condition, irreparable damage to the organism may occur. The risk of impairment of renal activity is significantly increased by the triggering drugs. In the case of an unfavorable course of the disease, permanent complications may therefore occur despite all efforts. In addition, seizures may occur, which can also trigger irreversible changes. An improved prognosis is achieved by immediately initiating an increased intake of fluids in addition to consulting a physician.

Prevention

Because malignant neuroleptic syndrome usually occurs as a side effect of medications, prevention of the condition is not possible, only averting it by immediately discontinuing the causative medications. For this purpose, it is important to pay close attention to any side effects and changes in relation to the body when taking the medication and to take them very seriously. In addition, since the likelihood of a malignant neuroleptic syndrome recurring is significantly increased, it is very important to approach the restart of neuroleptic therapy very carefully and sensitively. Ideally, atypical neuroleptics are prescribed and taken at the lowest possible dosage to keep the risk low from the start. Similarly, if a change of physician is pending, it is important to inform a new medical professional about the previous illness if taking appropriate medications is planned.

Follow-up

Drug allergy is usually not curable. To avoid discomfort, the patient must discontinue the medication in question and not take it in the future. This is the only way to prevent recurrence of the disease. This requires a high degree of personal responsibility in everyday life. Aftercare in the case of neuroleptic syndrome is basically aimed at addressing complications in a preventive manner. This is particularly important in life-threatening situations. Since treatment takes place within a few minutes, such knowledge can be vital. Since drug intolerance is constant, the most effective aftercare lies in protecting against dangerous consequences. This can only be done by avoiding any substances.

This is what you can do yourself

If irregularities or abnormalities occur while taking neuroleptics, the affected person should, in his or her own interest, seek discussion with the attending physician. Because malignant neuroleptic syndrome is treated in an intensive care unit, the options for self-help are very limited. Delays in consulting a physician result in rapid deterioration of health and should be avoided. The disease is associated with numerous symptoms and complaints, which often represent an excessive demand on the part of the ill person as well as his or her relatives. Emerging fears and worries of all involved should not become too strong. It is urgent to refrain from getting involved. Exchanges with relatives, therapists or other patients can be helpful. Language barriers can be overcome with digital aids or via sign language. Basically, a positive basic attitude towards life and its challenges is important. It helps to cope with what is happening and leads to new possible solutions. Thinking should be positive and at the same time realistic. It is helpful to set new goals that are achievable and do not cause further stress. In order not to suffer from additional illnesses, a healthy lifestyle is important. A healthy diet, optimized sleeping conditions and the supply of sufficient oxygen strengthen the immune system and promote well-being.At the same time, refrain from consuming harmful substances such as alcohol or nicotine.