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PubMed2005

Neuroleptic malignant syndrome due to three atypical antipsychotics in a child.

Neuroleptic Malignant Syndrome (NMS) is a rare, potentially fatal and idiosyncratic drug reaction. It is characterized by a sudden loss of body temperature control, renal and respiratory failure, muscle rigidity, loss of consciousness and impairment of autonomic nervous system. Although NMS was previously associated with the use of classical high-potency neuroleptics, cases have started to emerge with atypical neuroleptics. This article discusses the first case of NMS in a child, induced by the use of risperidone, olanzapine and quetiapine.

Aggression↗
PubMed2003

Movement disorders in children: definitions, classifications, and grading systems.

Disorders that affect movement in children are relatively common. However, they have received little attention, especially when compared with epilepsy and neuromuscular disorders. In this review article, we address the major types of movement disorders that affect children, their clinical characteristics and etiologies, and, when available, the scales used to grade them. A discussion on spasticity, which traditionally is not addressed in reviews of "movement disorders," is also included.

Ataxia↗
PubMed2003

Pathophysiology of pediatric movement disorders.

Pediatric movement disorders constitute a relatively small cluster of symptoms that can be associated with many different underlying diseases. To provide effective treatment, it is essential to understand the relationship between etiology and clinical expression. This article reviews the recent literature on several common pediatric movement disorders, including spasticity, dystonia, chorea, myoclonus, bradykinesia, and tics, and it discusses current models of physiology that may help link the cellular pathology of specific diseases to the expression of clinical symptoms.

Ataxia↗
PubMedDate not supplied

The DaNeX study of embryonic mesencephalic, dopaminergic tissue grafted to a minipig model of Parkinson's disease: preliminary findings of effect of MPTP poisoning on striatal dopaminergic markers.

A multicenter study is under way to investigate the efficacy of allografting of embryonic mesencephalic neurons in a pig model of Parkinson's disease. We have first established that a stable parkinsonian syndrome can be established by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) intoxication of adult male Göttingen minipigs. We are now using positron emission tomography (PET) methods for testing the physiological responses to MPTP intoxication and the time course of the response to several treatment strategies. We now report preliminary results obtained in 11 pigs employed in the initial phase of the study; the completed study shall ultimately include 30 pigs. Animals were randomly assigned to one of five groups: 1) Control, 2) MPTP intoxication, 3) MPTP intoxication followed by allograft, 4) MPTP intoxication followed by allograft with immunosuppression, and 5) MPTP intoxication followed by allograft with immunosuppression and co-grafting of immortalized HiB5 cells, which had been manipulated to secrete glia cell line-derived neurotrophic factor (GDNF) (approximately 2 ng GDNF/h/10(5) cells). MPTP was administered (1 mg/kg/day, SC) for 7-10 days until the pigs had developed mild parkinsonian symptoms of muscle rigidity, hypokinesia, and impaired coordination, especially of the hind limbs. Approximately 2 weeks after the last MPTP dose, animals received a T1-weighted magnetic resonance imaging (MRI) scan, and a series of dynamic PET recordings. After the first series of PET scans, four grafts of porcine embryonic mesencephalic tissue (E28 days) were placed in each striatum of some MPTP-intoxicated pigs, using MRI-based stereotactic techniques. Immunosuppression of some animals with cyclosporin and prednisolone began just prior to surgery. Two more series of PET scans were performed at 4-month intervals after surgery. After the last scans, pigs were killed and the brains were perfused for unbiased stereological examination of cytological and histochemical markers in striatum and substantial nigra. The behavioral impairment of the animals (the "Parkinson's score") had been evaluated throughout the 8-month period. Kinetic analysis of the first set of PET scans has indicated that the rate constant for the decarboxylation of FDOPA in catecholamine fibers was reduced by 33% in striatum of the mildly parkinsonian pigs. The rate of association of [11C]NS-2214 to catecholamine uptake sites was reduced by 62% in the same groups of pigs. No significant difference was found in the binding potential of [11C]raclopride to the dopamine D2-like receptors in striatum of the MPTP-intoxicated versus control pigs. These preliminary results are suggestive that the activity of DOPA decarboxylase may be upregulated in the partially denervated pig striatum.

Animals↗
PubMed1988

Neuroleptic rechallenge after neuroleptic malignant syndrome: case report and literature review.

Neuroleptic malignant syndrome (NMS) is associated with essentially all of the currently available antipsychotic agents. The signs and symptoms associated with the syndrome are hyperpyrexia, defined by body temperature greater than 38 degrees C; extreme muscle rigidity, with or without elevated creatine phosphokinase or hyperreflexia; and other symptoms such as altered level of consciousness and/or autonomic dysfunction as manifested by labile blood pressure, tachycardia, tachypnea, urinary or fecal incontinence, pallor, or diaphoresis. This potentially fatal syndrome complicates the treatment of patients with recurrent psychotic symptoms because of the possibility for recurrence of the NMS. A case of recurrent NMS is presented in which the patient was rechallenged with an antipsychotic agent. In addition, 41 reported cases of antipsychotic rechallenge after NMS are reviewed. The results of the review suggest that neuroleptic rechallenge following NMS is associated with an acceptable risk of recurrence in most patients. However, close monitoring for NMS and careful selection of patients for antipsychotic rechallenge is mandatory. A minimal time period of five days before rechallenge may also reduce the risk of recurrent NMS. Recurrence was not associated with patient age or gender, nor the antipsychotic agent used.

Antipsychotic Agents↗
PubMedDate not supplied

Risperidone-induced neuroleptic malignant syndrome.

OBJECTIVE: To describe a patient with neuroleptic malignant syndrome (NMS) induced by risperidone, an atypical antipsychotic, and to review the available literature related to risperidone-associated NMS. DATA SOURCE: Case report information was obtained from the resident physician and medical records. MEDLINE and Index Medicus were searched to obtain literature published between 1960 and 1995. DATA SYNTHESIS: We report an adolescent boy who developed NMS after treatment with risperidone. Risperidone therapy was started after unsuccessful treatment and development of extrapyramidal adverse effects with haloperidol. The patient demonstrated the classic tetrad of fever, generalized skeletal muscle rigidity, altered mental status, and autonomic dysfunction. Risperidone was discontinued and the patient recovered after a prolonged hospital course with supportive management. CONCLUSIONS: Clinicians are cautioned about the possibility of NMS with risperidone.

Adolescent↗
PubMed2005

Malignant hyperthermia.

Malignant hyperthermia (MH) is a rare genetic condition which may manifest for the first time during anaesthesia associated with a routine surgical procedure. Characterised initially by muscle rigidity, increased body temperature and metabolic acidosis, the syndrome may prove fatal unless prompt, effective treatment is administered. The sudden development of MH constitutes a medical emergency; hence it is essential that theatre practitioners are knowledgeable about the presenting symptoms and management of the condition.

Anesthesia, General↗
PubMed1999

Acute basagran poisoning mimicking neuroleptic malignant syndrome.

A 27-year-old robust man, without any medical and surgical history, attempted to commit suicide by consumption of 300 cc (44.1%, 132.3 g) basagran, a readily available herbicide. This poisoning resulted in vomiting, fever, sweating, pipe-like muscle rigidity, sinus tachycardia, drowsiness, leukocytosis, rhabdomyolysis and hepatorenal damage. Emperical treatment with bromocriptine was temporally associated with resolution of above signs and symptoms. His clinical presentations and the effect of bromocriptine may be indicative that basagran poisoning mimicks neuroleptic malignant syndrome.

Adult↗
PubMed1991

"Pseudospasticity" in Guillain-Barré syndrome.

We report a woman with Guillain-Barré syndrome who developed a flexion posture of the right arm and hand resembling upper motor neuron dysfunction. EMG demonstrated that involuntary peripherally generated continuous motor unit discharges caused the posture.

Aged↗
PubMed1987

Selective increase in cytoplasmic calcium by anesthetic in lymphocytes from malignant hyperthermia-susceptible pigs.

Anesthetic-induced malignant hyperthermia in pigs and humans is characterized by muscle rigidity and rapid, often fatal, increases in body temperature. A defect in Ca2+ homeostasis has been suspected as underlying the disease, based on the preventive effect of dantrolene sodium, an agent thought to reduce Ca2+ levels in the cytoplasm. We describe here direct measurements of cytoplasmic ionized Ca2+ levels in lymphocytes from seven normal and 12 malignant hyperthermia-susceptible pigs, using the fluorescent indicator quin2. No differences in the concentration of cytoplasmic ionized Ca2+ were found in cells from malignant hyperthermia-susceptible pigs (160 +/- 10 nM) relative to the controls (150 +/- 10 nM). However, addition of halothane in vitro caused a significant increase (to 270 +/- 30 nM) in lymphocytes from malignant hyperthermia-susceptible pigs, but not from normal pigs (180 +/- 10 nM). The halothane-mediated increase in cytoplasmic ionized Ca2+ required extracellular Ca2+. It is suggested that general anesthetics such as halothane increase the permeability of the cell surface to Ca2+, and that this increase may, on its own or indirectly, increase the cytoplasmic level of ionized Ca2+ during a malignant hyperthermia crisis. The detection of a halothane-dependent increase in cytoplasmic ionized Ca2+ selectively in malignant hyperthermia-susceptible pigs could be the basis for a noninvasive test for malignant hyperthermia.

Aminoquinolines↗
PubMed1983

Effects of propranolol on barbital dependence formation and withdrawal signs.

We studied the involvement of beta-adrenoceptors in the physical dependence formation of barbital. 1. Propranolol (at a dose of 0.5 or 1.0 mg/g food) and barbital were applied simultaneously as a mixture with animal food (barbital-propranolol combination). Barbital was applied on a schedule of gradually increasing dosages from 0.5-and-1.0 to 6-and-8 mg/g food over 36 days. Only the animals dosed with barbital exhibited severe withdrawal signs such as spontaneous withdrawal convulsions. The animals dosed with propranolol alone showed no changes even on withdrawal of the drug. The formation of physical dependence on barbital was obviously inhibited by the combination of barbital and propranolol. 2. Cross-application of propranolol (30 and 60 mg/kg, p.o., and 10 and 30 mg/kg, i.p.) following withdrawal of barbital resulted in the inhibition of the spontaneous withdrawal convulsions, muscle rigidity and hyperirritability. It also inhibited significantly tranylcypromine-induced convulsions, while it failed to inhibit similarly induced hyperthermia. These results including previous findings of effects of monoamine-related compounds on barbital withdrawal convulsions suggest that the balance of activities of noradrenergic neurons, especially that of alpha- and beta- receptors, has great influence on both the formation of physical dependence on barbital and the manifestation of withdrawal convulsions.

Animals↗
PubMed1985

Sex differences in the induction of physical dependence on pentobarbital in the rat.

Sex differences in physical dependence on sodium pentobarbital in the rat were studied by the drug-admixed food (DAF) method. With male rats, the concentration of pentobarbital in the food was gradually increased from 2 to 30 mg/g over a period of 50 days. The final level of drug intake was approximately 1.7 g/kg/day. At pentobarbital concentrations of 20 and 22 mg/g of food, sedation and mild muscle relaxation were observed. At the highest drug concentration, 30 mg/g of food, marked muscle relaxation was noted. With female rats, the concentration of pentobarbital in the food was gradually increased from 1 to 16 mg/g over a period of 47 days. The final level of intake was approximately 1.0 mg/kg/day. At drug concentrations of 12 and 14 mg/g, sedation and mild muscle relaxation appeared. At 16 mg/g, female rats showed marked muscle relaxation similar to that of the male rats. To produce severe loss of muscle tone, the male rats required twice as much pentobarbital as the female rats. After substitution of normal food for the pentobarbital-admixed food, various signs of pentobarbital withdrawal occurred in both sexes. These signs included vocalization, irritability, muscle rigidity, tremors and convulsions. Onset of withdrawal was more rapid in the females, and the maximum weight loss was greater, 8.0% compared to 3.8% in the males. Physical dependence on pentobarbital was easily developed in both sexes by the DAF method. There was a marked sex difference in withdrawal which we attribute to sex differences in drug metabolizing enzyme activity.

Animals↗
PubMed1998

Role of propofol in refractory status epilepticus.

OBJECTIVE: To provide a review of the proposed mechanism of action, clinical efficacy, adverse effects, and therapeutic considerations associated with the use of propofol in the management of patients with refractory status epilepticus. DATA SOURCES: A MEDLINE database (January 1966-April 1998) was searched for literature pertaining to status epilepticus and propofol. Additional literature was obtained from the references of selected articles identified in the search. Information from all articles published in English was considered for inclusion in the article. DATA SYNTHESIS: Propofol is a unique, nonbarbiturate, anesthetic agent possessing anticonvulsant properties, although the exact anticonvulsant mechanism is unknown. Several case reports and two small, open, uncontrolled studies have described the efficacy of propofol in refractory status epilepticus. Most of these clinical reports discuss the utility of propofol after traditional treatment regimens have failed or are not tolerated. Initiation of propofol usually resulted in termination of seizure activity and/or electroencephalographic burst suppression within seconds that was sustained during the drug's use. Additionally, propofol was well tolerated. Advantages of propofol compared with traditional barbiturate anesthetic agents include better cardiovascular tolerability and a more favorable pharmacokinetic profile, allowing for rapid assessment of efficacy and neurologic assessment upon drug withdrawal. Propofol has been associated with a variety of neuroexcitatory adverse events such as opisthotonos, muscle rigidity, and choreoathetoid movements. Additionally, although the data are inconclusive, propofol has also been reported to cause seizures. CONCLUSIONS: Propofol has shown promising results in the management of refractory status epilepticus when traditional therapies have failed or were not tolerated; however, controlled clinical trials are needed to better assess the comparative efficacy, neurologic adverse effects, and clinical outcome to better define its role in refractory status epilepticus.

Anticonvulsants↗
PubMed2005

Fluphenazine-induced neuroleptic malignant syndrome in a schizophrenic patient.

OBJECTIVE: To report a case of neuroleptic malignant syndrome (NMS) associated with fluphenazine in a schizophrenic patient and review the literature related to this condition. CASE SUMMARY: A 21-year-old African American male with schizophrenia came to our medical intensive care unit from the crisis intervention unit (CIU). He was hyperthermic (oral temperature 40.6 degrees C), diaphoretic, tachycardic (heart rate 140 beats/min), and tachypneic (respiratory rate 22 breaths/min), with severe muscle rigidity and shaking tremors. He had an extensive psychiatric history significant for schizophrenia and multiple past hospital admissions, starting at age 14 years. Two days prior to admission to the CIU, he had been given 25 mg of fluphenazine decanoate injection intramuscularly in addition to his regular psychotropic regimen of thioridazine and haloperidol after reportedly making several verbal threats and displaying aggressive behavior toward the personnel at the group home where he resided. Laboratory studies showed elevated creatine kinase, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase levels, as well as azotemia, hyperphosphatemia, hypocalcemia, and leukocytosis. DISCUSSION: NMS is a rare but potentially fatal reaction associated with neuroleptic drugs. It occurs in approximately 0.07-2.2% of patients treated with neuroleptics. Risk factors include previous episodes, dehydration, agitation, polypharmacy, and the rate and route of neuroleptic administration. CONCLUSIONS: An objective causality assessment revealed that fluphenazine was the probable cause of NMS in this patient. There was no reaction associated with thioridazine and/or haloperidol. Clinicians need to be aware of this drug-induced condition and the potential increased risk associated with concurrent use of multiple psychotropics.

Adult↗
PubMed1978

Preoperative and operative considerations in malignant hyperpyrexia.

Malignant hyperpyrexia is a condition characterized by fever and often by skeletal muscle rigidity usually triggered by the administration of general anesthetic agents. A review of the current literature is given to emphasize preoperative and operative considerations. An uncomplicated case is presented to illustrate the special care that these individuals require.

Adult↗
PubMed1993

Thyroid dysfunction in isolated adrenocorticotropic hormone (ACTH) deficiency: case report and literature review.

A case of isolated ACTH deficiency accompanying transient primary hypothyroidism was reported along with a review of literature on isolated ACTH deficiency in Japan with special reference to its association with thyroid function. Our case, a 56-year-old woman, developed somnolence and hypoglycemia due to isolated ACTH deficiency. She also had the features of hypothyroidism, namely mounding phenomenon, muscle rigidity, increased plasma myogenic enzymes and cold intolerance. Both free T3 and free T4 were decreased, and basal as well as TRH-stimulated TSH levels were abnormally high. Plasma thyroglobulin was increased and no anti-thyroid antibodies were detected. All thyroid related physical and biochemical abnormalities disappeared after hydrocortisone replacement. A review of the literature on 103 cases disclosed that more than half the cases with isolated ACTH deficiency had a high plasma level of TSH, basal and/or TRH-induced, while the antithyroid antibodies were reported to be positive in only 13 cases. In more than 70% of such cases, the abnormality in the pituitary-thyroid axis was transient and was reversed by glucocorticoid replacement. Our case and cases in the literature indicate that the interference of thyroid hormone synthesis and/or secretion by glucocorticoid deficiency per se is the major cause of thyroid dysfunction rather than associated autoimmune thyroid disease.

Adolescent↗
PubMed2004

Psychotic symptoms in Parkinson's disease: pathophysiology and management.

Parkinson's disease (PD) is a chronic neurodegenerative disease, in which mainly dopaminergic neurons in the substantia nigra in the brain degenerate, leading to a depletion of dopamine (DA) in the striatum. The most important motor disturbances of the disease are bradykinesia (slowing down of movement), hypokinesia (poverty of movement), rigidity (muscle stiffness), tremor and postural instability. Besides these well-known motor symptoms, non-motor symptoms may develop, such as depression, cognitive impairment and psychosis. Psychotic symptoms constitute a relatively common but nevertheless serious complication, with visual hallucinations and paranoid delusions often being most prominent. These symptoms are important contributors to patient and caregiver distress and are often important risk factors for nursing home placement. Exogenous (related to therapeutic interventions) factors are of major importance but endogenous (related to the disease process itself) factors might also contribute to the development of psychotic symptoms in PD. Therapeutic strategies comprise reduction of antiparkinsonian treatment, cholinesterase inhibitors and atypical antipsychotics. As psychotic symptoms in PD are often influenced by both endogenous and exogenous factors, a combination of strategies may be chosen.

Antipsychotic Agents↗