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Neuroleptic Malignant Syndrome in a Patient With Parkinson's Disease: A
Case Study

Abstract: Neuroleptic malignant syndrome (NMS) is a potentially lethal
condition that has been described in patients with idiopathic Parkinson's
disease (PD) after long-term dopaminergic medications are suddenly stopped
or moderately decreased. If patients with PD develop severe rigidity,
stupor, and hyperthermia, L-Dopa withdrawal should be suspected and the
dopaminergic drug restarted as soon as possible to prevent rhabdomyolysis
and renal failure. Nurses who are knowledgeable about NMS can provide
prompt identification of the PD patient's condition and prevent a
potentially lethal cascade of symptoms.

A 72-year-old white male diagnosed with Parkinson's disease (PD) 14 years
ago, presented to our clinic with a temperature of 102.5F, decreased mental
status, rigidity, and stiffness. The patient's wife reported that her
husband's freezing episodes had intensified over the past week and that his
mental status had declined. His weakness and confusion caused him to spend
the previous night on the bathroom floor. The fire department was called
the next day to assist her in rifting him so she could transport him to the
hospital. One month before this incident, the patient had a bilateral deep
brain stimulator (DBS) placed into his basal ganglia to treat tremors and
dyskinesias related to PD. The surgical hospital course had been unremarkable.

Physical Examination

The patient presented with altered mental status, inability to follow
commands, hallucinations, confusion, and inability to ambulate or perform
activities of daily living. His temperature was 102.5F, and his neck and
extremities were rigid. There were resting pronation and supination tremors
of both hands, with marked pill- rolling actions of the fingers. Mild to
moderate dysarthria, hypophonia with a monotone voice, and hypomimia were
observed. Surgical sites were healed without signs of infection. Blood
pressure was normal to hypotensive, and the patient was tachycardie. The
findings of the rest of the examination were unremarkable.

A neurologist reviewed preoperative and postoperative medications and
discovered that the carbidopa/ levodopa 25 mg/100 mg dose had been reduced
by tab every 3 hours after the DBS implant had been turned on and
programmed according to presenting PD symptoms. Pramipexole was continued
at 0.5 mg tid, and selegiline 5 mg qd had been discontinued.

Abnormal Diagnostic Tests/Results

The abnormal laboratory test results found at the time of admission gave an
indication that immediate intervention was required (Table 1). A chest X
ray revealed a few interstitial lung markings consistent with shallow
inspiration, but were otherwise normal. A lumbar puncture was negative for
infection, and an electrocardiogram revealed tachycardia. A magnetic
resonance imaging (MRI) brain scan demonstrated normal brain parenchyma,
evidence of metallic electrodes in the basal ganglia, and no evidence of
acute abnormality. Cultures and sensitivities of blood, cerebrospinal
fluid, sputum, and urine were obtained. The sputum culture revealed
moderate Pseudomonas aeruginosa; the rest of the cultures remained negative
for 72 hours. A large amount of blood and protein, without bacteria, was
noted in the urine specimen. Because of the uncertainty of the diagnosis,
tests also were obtained for fecal leukocytes, St. Louis encephalitis IgM,
and West Nile virus IgM; all these tests were negative. The admitting
diagnosis was possible pneumonia, rhabdomyolysis, and urinary tract
infection. By the second day of his hospitalization, the patient's
condition met the diagnostic criteria for neuroleptic malignant syndrome
(NMS) secondary to dopamine withdrawal.

A definite diagnosis of NMS requires both essential features and associated
symptoms, which are listed in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV, American Psychiatric Association, 2000). The
essential symptoms exhibited by the patient that allowed for this diagnosis
were hyperthermia and severe muscle rigidity. His associated symptoms
included changes in level of consciousness, leukocytosis, tachycardia,
diaphoresis, incontinence, and laboratory evidence of muscle injury in the
form of extreme elevations of creatine kinase (CK) levels (12,542 U/L)
(Nicholson & Chiu, 2004).

Major Nursing Issues

This patient's major nursing issues were hyperthermia, possible
dehydration, stiffness and rigidity, and altered mental status. All of
these conditions rendered him unable to perform his activities of daily
living. Nurses played a major role in providing supportive care, including
adequate hydration, proper nutrition, and fever reduction.

Table 1. Laboratory Tests on Admission

Table 2. Laboratory Tests on Hospital Day 7

The patient's presenting symptoms and abnormal laboratory values provided
nurses with clinical information that required them to take action before a
diagnosis was made by the neurologist. The 102.5F fever was critical and
predisposed this patient to seizures and further dehydration. The nurse
administered antipyretics for hyperthermia and intravenous (IV) fluids.
Dantrolene sodium (Dantrium) was ordered as a direct-action muscle
relaxant. This drug acts directly on skeletal muscle to interfere with
intracellular calcium movement. By blocking the calcium release from the
muscle, the activation of acute catabolism associated with neuroleptic
malignant syndrome is halted, thus reducing the risk of rhabdomyolysis
(Maloni & Ross, 2004). Anticoagulant therapy, such as heparin, may be
ordered to prevent disseminated intravascular coagulation (DIC).

Comfort measures for the patient included tepid sponge baths and placement
on a temperature-regulating blanket to decrease temperature elevations. Due
to abnormalities in his chest X ray and arterial blood gas (ABG) analysis,
this patient needed to cough and deep-breathe several times every hour to
clear secretions that cause pneumonia. He also needed oxygen by nasal
cannula at 2-3 liters to increase his blood oxygen level and promote
bronchodilation; this oxygenation also improved his mental status.
Antibiotics were administered as ordered.

The elevated blood urea nitrogen (BUN) indicated that he probably was
dehydrated. Although the BUN is directly related to the metabolic function
of the liver, it also represents the excretory function of the kidney. The
nurse placed a urinary catheter to monitor his urine output, expecting at
least 30 cc/hour to ensure adequate kidney function. The nurse began IV
fluids of 0.9% normal saline at 90 cc/hour because his sodium level was
slightly abnormal (131 mmol/L), and monitored oral and IV fluid intake. His
urine specific gravity of 1.026 was another indication of dehydration.
Although creatinine clearance was normal, protein in his urine indicated
kidney function was abnormal.

The presence of large amounts of blood in the urine may have indicated
ensuing rhabdomyolysis, a condition with extreme enzyme elevations caused
by skeletal muscle destruction. These high enzymes could mean many things,
but primarily indicates muscle catabolism and injury possibly caused by
hyperthermia and muscle rigidity. The patient's troponins were normal,
which ruled out cardiac muscle involvement. Empiric antibiotic therapy was
started to cover the elevated white blood cell (WBC) count and sputum
pseudomonas. Dopaminergic medications were administered at the preoperative
level to restore dopamine levels.

Discussion

NMS is an uncommon, life-threatening, idiosyncratic reaction to the acute
withdrawal of anti-Parkinsonian agents (Sanga & Nomura, 2003). The observed
clinical signs demonstrating autonomie dysfunction are hyperthermia,
tachycardia, tachypnea, diaphoresis, altered consciousness, and hyper- or
hypotension. Other signs of NMS include rigidity, leukocytosis, tremors,
and marked elevation of serum CK. A serious complication of NMS is
rhabdomyolysis, which is an acute, fulminating, and potentially fatal
disease of the skeletal muscles that destroys muscle tissue. It is
evidenced by extreme CK levels (12,542 U/L in this patient) , hyperkalemia,
myoglobinuria, and acute renal insufficiency. The patient maintained normal
serum potassium levels and urinary output and did not develop
rhabdomyolysis. With conditions that may involve damage to skeletal muscle,
hydration should be adequate to dilute the urine and flush the myoglobin
out of the kidney to prevent rhabdomyolysis from occurring (Craig, 2004).
Other complications of NMS include respiratory failure, myocardial
infarction, hepatic failure, and DIC. The mortality rate is 15%-20% (Davis,
Caroff, & Mann, 2000). There have been more than 200 cases of NMS in older
adults reported in the medical literature (Nicholson & Chiu, 2004). It
appears that even a moderate withdrawal of dopaminergic agents in the older
Parkinson's patient may trigger NMS. Older patients may be more susceptible
to NMS because dopamine activity decreases with age (Nicholson & Chiu).

Outcomes

Data indicate the average duration of NMS is approximately 7-10 days (Davis
et al., 2000). By the 4th hospital day, his mentation cleared and the
elevated enzymes were decreasing. The WBC was normal and hemaruria and
proteinuria were absent. Serum sodium level had normalized as well as the
BUN. Table 2 demonstrates that the patient's laboratory results returned to
normal on day 7 of his hospital admission and resolution of \NMS, and
coincides with this patient's recovery time. The DBS was turned off on day
7 to prepare for a brain MRI with contrast and because the neurologist
wanted to monitor the patient off stimulation for 5 days before it was
restarted on day 13 at its preadmission settings. Tremor was visible off
stimulation during those 5 days.

This patient survived NMS through the prompt treatment and supportive care
given to him upon his hospital admission. However, he required intensive
inpatient physical and occupational therapy because of his prolonged
bedrest. The length of stay for this hospital admission was 23 days.

Summary

To prevent NMS in Parkinson's patients, nurses must be cognizant of the
narrow safety margin for withdrawing dopaminergic agents. The presence of
NMS poses a significant mortality risk for the fragile geriatric
population. Nurses who understand this critical condition and who are
knowledgeable about the risks, warning signs, and treatment for NMS are
able to explain to worried family members the course of treatment and offer
realistic hope for a complete recovery.

Acknowledgment

Special thanks to Naomi Nelson, PhD RN, for editing expertise.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual
of mental disorders: DSM-IV-TR (pp. 795-798). Washington, DC: Author.

Craig, S. (2004, December 29). Rhabdomyolysis. Retrieved February 8, 2005,
from http://www.emedicine.com/emerg/topic508.htm

Davis, J. M., Caroff, S. N., & Mann, S. C. (2000).Treatment of neuroleptic
malignant syndrome. Psychiatric Annals, 30,325-334.

Maloni, H., & Ross, A. R (2004). Degenerative disorders. In M.K. Bader &
L.R. Littlejohns, (Eds.), AANN core curriculum for neuroscience nursing,
(4th ed.), St. Louis, MO: Saunders.

Nicholson, D., & Chiu.W (2004). Neuroleptic malignant syndrome. Geriatrics
Advisor, 59(8), 36-40.

Sanga, M., & Nomura, S. (2003).A case of malignant syndrome associated with
a Parkinsonism patient. Japanese Journal of Psychopharmacology, 23,91-95.

Questions or comments about this article may be directed to Constance Ward,
MSN RN BC, Neurology Care Line-127PD 2002 Holcombe Blvd., Houston, TX
77030, or by e-mail to constance. [log in to unmask] She is a clinical
coordinator, Parkinson's Research, Education & Clinical Center, Michael E.
DeBakey VA Medical Center, Houston, TX.

Copyright 2005 American Association of Neuroscience Nurses 0047-
2606/05/3703/0000160$5.00

Copyright American Association of Neurosurgical Nurses Jun 2005



Source: Journal of Neuroscience Nursing

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