Case Report

Atypical Neuroleptic Malignant Syndrome Presenting as Fever of Unknown Origin in the Elderly

Authors: Ryan C.W. Hall, MD, Brian Appleby, MD, Richard C.W. Hall, MD

Abstract

A 79-year-old nursing home resident who was taking olanzapine presented to multiple hospitals with fevers of unknown origin. After an extensive workup to rule out infection, the patient was diagnosed as having neuroleptic malignant syndrome (NMS). This patient’s presentation was atypical because of the lack of rigidity or tremor at the time of admission. This case highlights the importance of including NMS in the differential diagnosis of fever of unknown origin in medical patients. A review of the medical literature is taken, focusing on diagnoses, prevalence, predisposing factors, pathophysiology, and current treatment approaches for NMS.


Key Points


* Neuroleptic malignant syndrome is a rare but important condition to be included in the differential diagnosis of fever of unknown origin for medical patients, especially those with predisposing factors.


* Neuroleptic malignant syndrome may have a forme fruste presentation, with delayed onset of or the absence of rigidity.


* Neuroleptic malignant syndrome can be caused by any neuroleptic medication (phenothiazines, thioxanthenes, or the newer atypical antipsychotics) and by other classes of medication commonly used in hospitals, such as antiemetics (prochlorperazine), pro-peristaltic agents (metoclopramide), anesthetics (droperidol), and sedatives (promethazine).


* The most significant factor for predicting death in cases of neuroleptic malignant syndrome (50% correspondence rate) is the new onset or worsening of renal failure.


* Continuing a patient on an equipotent neuroleptic medication at the same dose as before an episode of neuroleptic malignant syndrome leads to a relapse rate of 80%.

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