NEUROLEPTIC MALIGNANT SYNDROME - 3 ADOLESCENTS WITH COMPLICATED COURSES

Neuroleptic malignant syndrome (NMS) with serious complications is des cribed for three adolescent males. Complications included extensive mu scle necrosis with creatine phosphokinase (CPK) increased to 48,900 U/ L, anticholinergic toxicity with fever and central anticholinergic syn drome, and brachial plexus injury, which mimicked an intracranial lesi on. Such complications can interfere with prompt diagnosis of NMS and thereby contribute to its severity. Consistent with the phenomenology described for adults, all three adolescents presented with muscle rigi dity, hyperthermia, elevated CPK, and a varied constellation of other abnormalities. Risk factors appeared to include male gender, underlyin g organicity, and the use of high-potency neuroleptic medication. All youths had been treated with haloperidol. Other factors may have contr ibuted to the onset of NMS, including the final dosage, the rate of in crease of haloperidol, the recent switch from a lower potency antipsyc hotic, and the concomitant use of other psychiatric medications. Treat ment consisted of the discontinuation of haloperidol and supportive in tervention. Additionally, all youths were treated with the dopamine ag onists amantadine and bromocriptine, and one youth received the skelet al muscle relaxant dantroline. All recovered from their severe NMS epi sodes. Within a few days of NMS defervescence, two youths were rechall enged with a lower potency antipsychotic without NMS recurrence. These cases illustrate the complexity of neuroleptic side effects and the p olymorphous presentation of NMS. They suggest that any deterioration i n the clinical course of neuroleptic-treated adolescents should lead t o inclusion of NMS in the differential diagnosis. Despite serious comp lications, full recovery from NMS is possible with aggressive supporti ve treatment.