SHM Converge Scientific Abstract ePoster Gallery-A Diagnostic Conundrum: A Complex Case of Neuroleptic Malignant Syndrome

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This case report describes a 42-year-old man with alcohol use disorder, major depressive disorder, and prior suicide attempt who was admitted after a gabapentin overdose while intoxicated. He remained on sertraline and was started on trazodone for insomnia, later uptitrated, with hydroxyzine added. Three weeks later, he developed diaphoresis, tremors, gait instability, and diffuse rigidity. Initial findings showed mild leukocytosis, elevated creatine phosphokinase, and acute kidney injury, but no hyperreflexia or clonus, making alcohol withdrawal and serotonin syndrome less clear.<br /><br />The diagnosis was complicated by his history of repeated alcohol withdrawal admissions and an unwitnessed report that he had taken unknown “anti-anxiety” pills from his mother. Because neuroleptic malignant syndrome (NMS) can present with rigidity, autonomic instability, altered mental status, leukocytosis, and elevated CPK, it was considered despite the absence of classic antipsychotic exposure. The authors note that SSRIs, and medications such as trazodone and hydroxyzine, may contribute to reduced dopaminergic activity and have been associated with NMS.<br /><br />The patient was later intubated for respiratory depression, and psychotropic medications were stopped. He had further episodes of agitation and rigidity while receiving ketamine and propofol. Empiric bromocriptine led to improvement in rigidity, and he was extubated six days later and discharged on a bromocriptine taper.<br /><br />The main lesson is that NMS can closely resemble alcohol withdrawal, serotonin syndrome, catatonia, and malignant hyperthermia. Clinicians should maintain a high index of suspicion for NMS when patients take an SSRI along with other medications that may lower dopaminergic tone.

Asset Subtitle

Aparna Rathnam

Meta Tag

Author List Alberto Busmail Haylock, Aparna Rathnam, Harleen K. Sidhu, Mohamed Abdelghffar, Thanushiree Sivalingam

Category Clinical Vignettes

Concept Neuroleptic Malignant Syndrome

Concept Antipsychotic

Concept Drug Discontinuation

Concept Serotonin Syndrome

Concept Alcohol Withdrawal

Distinguished Non-Finalist

Presenter Organization NYC Health + Hospitals / Elmhurst, Icahn School of Medicine at Mount Sinai.

Presenting Author Aparna Rathnam

Track Adult

Keywords

neuroleptic malignant syndrome

NMS

sertraline

trazodone

hydroxyzine

alcohol withdrawal

serotonin syndrome

gabapentin overdose

bromocriptine

rigidity

Neuroleptic Malignant Syndrome

Antipsychotic

Drug Discontinuation

Serotonin Syndrome

Alcohol Withdrawal