Neuroleptic malignant syndrome after an emergency operation for acute appendicitis perforation

Case report

A 62-year-old man with no history of psychiatric or neurological problems came to hospital after 3 days of severe abdominal pain and constipation. Diagnosed with acute abdomen secondary to acute appendicitis perforation, he underwent an emergency operation anesthetized with sevoflurane, propofol, sucdnylcholine chloride and cis-atracurium. On the fourth day after, he began to show symptoms of delirium and agitation. He was given haloperidol (3 mg orally and then a 5-mg ampoule intramuscularly), with good results. Within a few hours he was mildly lethargic but confused, responding to verbal stimuli but not answering questions appropriately. He had diffuse rigidity. His baseline temperature climbed to 38�C and he developed persistent hypertension (180/100 mm Hg), tachypnea (24 breaths/min) and tachycardia (110-140 beats/min). Neurological and physical examinations revealed no source of infection or intracranial pathology; results of cranial CT were normal. His leukocyte count rose from 11.4/mm^sup 3^ to 14.2 (normal range 3.6-9.6/mm^sup 3^), and other serum concentrations were high: creatinine phosphate 335 (normal 24-195) U/L, alanine aminotransferase 78 (normal 1-42) U/L and aspartate aminotransferase 64 (normal 1-37) U/ L. Serum electrolyte results were normal.

We entertained a diagnosis of neuroleptic malignant syndrome (NMS) and administered bromocriptine (15 mg/d for 15 days). The patient's confusion resolved, and his vital signs returned to normal.

Discussion

The cause of NMS is unknown. It is attributed by some to a primaiy dopamine-receptor blockade in the basal ganglia and hypothalamus, and to a disturbance of calcium uptake in skeletal muscle by others.1 The disease may be caused by a spectrum of inherited defects in genes responsible for a variety of calcium regulatory proteins within sympathetic neurons or the higher-order assemblies that regulate them.2

The clinical picture in NMS includes muscular rigidity, altered mental status and severe autonomie dysfunctions. It is associated with hyperthermia, elevated levels of plasma creatinine phosphate and leukocytosis.3

In recent years, there has been an increased awareness of the occurrence of NMS in surgical patients.l'4HS Its causative factors include an interruption or alteration of the administration of neuroleptic drugs, the added use of narcotics, and physical stress such as infection, dehydration, malnutrition and tissue injury.4

In emergency surgical patients whose condition is associated with severe tissue injury and infection, NMS symptoms are easily attributed to a surgical complication when these patients had no psychiatric or neurological history. We recommend that surgeons bear die possibility of NMS in mind.

Competing interests: None declared.

[Reference]

References

1. Liberman A, Pastcrnack P, Colvin S. The ncuroleptic malignant syndrome after open heart surgery: successful treatment with bromocriptine. NT State J Med 1987;87:362-3.

2. Gurrera RJ. Is neuroleptic malignant syndrome a neurogenic form of malignant hyperthermia? CHn Neuropharmacol 2002; 25:183-93.

3. Byrd C. Neuroleptic malignant syndrome: a dangerous complication of neuroleptic therapy. / Nearosci Nurs 1993;25:62-5.

4. Honda M, Ueo H, Inoue H, Nanbara S, Arinaga S, Asoh T, et al. Neuroleptic malignant syndrome occurring after an emergency operation for traumatic duodenal perforation: report of a case. Surg Today 1994;24:276-9.

5. Khun WF, Lippmann SB. Neuroleptic malignant syndrome as a possible postoperative complication: a case report. Gen Hasp Psychiatry 1987;9:179-81.

6. Brown FE, Nicrenberg DW, Nordgrcn RE, Taylor RM, Rozychi AA. Neuroleptic malignant syndrome: occurence in a child after reconstructive surgery. Plast Reconstr Surg 1991;87:961-4.

[Author Affiliation]

Ayse Tunca, MD;* Meral Sen, MD;[dagger] Cenap Dener, MD;[dagger] Ayca Bozoklu, MD;[double dagger] Orhan Murat Kocak, MD�

[Author Affiliation]

From the Departments of * Neurology, [dagger] General Surgery, [double dagger] Ancesthesiology and � Psychiatry, Fatih University Medical School, Ankara, Turkey

Accepted for publication Nov. 17, 2003

Correspondence to: Dr. Ayse Tunca, Fatih �niversitesi Tip Fak�ltesi, Ciftlik Caddesi No: 57, Emek 06510, Ankara, Turkey; tax +90 312 22-13-276; etunca@e-kolay.net