Background. Neuroleptic malignant syndrome (NMS) is a rare but life-threatening complication of neuroleptic drugs, which are used widely in head and neck cancer (HANC) patients who develop delirium. Methods and Results. Postoperative delirium in a 39-year-old man with tongue cancer was treated with haloperidol and chlorpromazine. Three days after the first administration of antipsychotics, the patient exhibited elevated body temperature, autonomic and extrapyramidal symptoms, and impaired consciousness. A definitive diagnosis was made using the research diagnostic criteria for NMS in the DSM-IV, and the antipsychotics were immediately discontinued. The patient was given dantrolene and bromocriptine to treat the NMS. The patient’s hyperthermia, elevated creatinin kinase (CK), and muscle rigidity improved gradually, with all symptoms of NMS resolving completely by 13 days after the diagnosis. Conclusions. HANC surgeons must be alert for early signs of NMS and use antipsychotics conservatively to avoid NMS and its potentially fatal outcome. 1. Introduction Neuroleptic malignant syndrome (NMS) is a rare but life-threatening disorder caused by an adverse reaction to neuroleptic (antipsychotic) drugs and characterized by hyperthermia, severe muscle rigidity, and changes in autonomic and mental status [1]. Most cases of clinical NMS have been reported by psychiatrists; however, NMS can occur in any setting in which psychotropic drugs are administered. In nonpsychiatric cases treated with neuroleptics, NMS can be difficult to diagnose, particularly because the symptoms are consistent with other, more expected, disorders. However, early diagnosis is extremely important to reduce the risk of death. The frequency of the syndrome ranges from 0.07 to 2.2% in patients treated with neuroleptic drugs, and the mortality is 10 to 30% [2, 3]. Although the frequency of NMS among patients taking neuroleptics has decreased, it remains a significant source of morbidity and mortality in this patient group [4]. To our knowledge, a few reports have been published about NMS in patients with head and neck cancer (HANC) [5, 6]. We report a rare case of NMS that occurred postoperatively in a tongue cancer patient whose surgery consisted of hemiglossectomy, neck dissection, and immediate reconstruction. 2. Case Report A 39-year-old man came to the Department of Oral and Maxillofacial Surgery, University of Tsukuba Hospital, complaining of a painful mass of the tongue border. His medical, social, and family histories were unremarkable. The diagnosis was tongue cancer (T2N1？M0). He
References
[1]
S. N. Caroff, “The neuroleptic malignant syndrome,” Journal of Clinical Psychiatry, vol. 41, no. 3, pp. 79–83, 1980.
[2]
P. Adnet, P. Lestavel, and R. Krivosic-Horber, “Neuroleptic malignant syndrome,” British Journal of Anaesthesia, vol. 85, no. 1, pp. 129–135, 2000.
[3]
S. Stübner, E. Rustenbeck, R. Grohmann et al., “Severe and uncommon involuntary movement disorders due to psychotropic drugs,” Pharmacopsychiatry, vol. 37, supplement 1, pp. S54–S64, 2004.
[4]
J. R. Strawn, P. E. Keck Jr., and S. N. Caroff, “Neuroleptic malignant syndrome,” The American Journal of Psychiatry, vol. 164, no. 6, pp. 870–876, 2007.
[5]
K. Tanaka, T. Akechi, M. Yamazaki, R. Hayashi, Y. Nishiwaki, and Y. Uchitomi, “Neuroleptic malignant syndrome during haloperidol treatment in a cancer patient: a case report,” Support Care Cancer, vol. 6, no. 6, pp. 536–538, 1998.
[6]
Y. Zohar, Y. P. Talmi, R. Sabo, Y. Finkelstein, and A. Korzets, “Neuroleptic malignant syndrome during perphenazine treatment in a patient with head and neck cancer: a case report,” Otolaryngology, vol. 106, no. 2, pp. 206–208, 1992.
[7]
A. P. Association, “Diagnostic and statistical manual of mental disorders: DSM-IV,” in Neuroleptic Malignant Syndrome, The American Psychiatric Association, Washington, DC, USA, 4th edition, 1994.
[8]
K. Nishijima, Neuroleptic Malignant Syndrome and Related Disoders, 1st edition, 2010.
[9]
B. H. Guze and L. R. Baxter Jr., “Neuroleptic malignant syndrome,” The New England Journal of Medicine, vol. 313, no. 3, pp. 163–166, 1985.
[10]
S. N. Caroff and S. C. Mann, “Neuroleptic malignant syndrome,” Medical Clinics of North America, vol. 77, no. 1, pp. 185–202, 1993.
[11]
K. Otani, M. Horiuchi, T. Kondo, S. Kaneko, and Y. Fukushima, “Is the predisposition to neuroleptic malignant syndrome genetically transmitted?” British Journal of Psychiatry, vol. 158, pp. 850–853, 1991.
[12]
K. Mihara, T. Kondo, A. Suzuki et al., “Relationship between functional dopamine D2 and D3 receptors gene polymorphisms and neuroleptic malignant syndrome,” The American Journal of Medical Genetics, vol. 117, no. 1, pp. 57–60, 2003.
[13]
R. D. Myers, “Neurochemistry of thermoregulation: two negatives make a positive,” Brain Research Bulletin, vol. 50, no. 5-6, pp. 453–454, 1999.
[14]
G. J. Chandran, J. R. Mikler, and D. L. Keegan, “Neuroleptic malignant syndrome: case report and discussion,” CMAJ, vol. 169, no. 5, pp. 439–442, 2003.
[15]
G. Tollefson, “A case of neuroleptic malignant syndrome: in vitro muscle comparison with malignant hyperthermia,” Journal of Clinical Psychopharmacology, vol. 2, no. 4, pp. 266–270, 1982.
[16]
J. L. Levenson, “Neuroleptic malignant syndrome,” The American Journal of Psychiatry, vol. 142, no. 10, pp. 1137–1145, 1985.
[17]
R. J. Gurrera, S. N. Caroff, A. Cohen et al., “An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method,” Journal of Clinical Psychiatry, vol. 72, no. 9, pp. 1222–1228, 2011.
[18]
A. Shalev and H. Munitz, “The neuroleptic malignant syndrome: agent and host interaction,” Acta Psychiatrica Scandinavica, vol. 73, no. 4, pp. 337–347, 1986.
[19]
D. Sierra-Biddle, A. Herran, S. Diez-Aja et al., “Neuroleptic malignant syndrome and olanzapine,” Journal of Clinical Psychopharmacology, vol. 20, no. 6, pp. 704–705, 2000.
[20]
V. R. Velamoor, R. M. G. Norman, S. N. Caroff, S. C. Mann, K. A. Sullivan, and R. E. Antelo, “Progression of symptoms in neuroleptic malignant syndrome,” Journal of Nervous and Mental Disease, vol. 182, no. 3, pp. 168–173, 1994.
[21]
H. G. Pope Jr., H. G. Aizley, P. E. Keck Jr., and S. L. McElroy, “Neuroleptic malignant syndrome: long-term follow-up of 20 cases,” Journal of Clinical Psychiatry, vol. 52, no. 5, pp. 208–212, 1991.
[22]
D. Berardi, M. Amore, P. E. Keck Jr., M. Troia, and M. Dell'Atti, “Clinical and pharmacologic risk factors for neuroleptic malignant syndrome: a case-control study,” Biological Psychiatry, vol. 44, no. 8, pp. 748–754, 1998.
[23]
W. S. Bond, “Detection and management of the neuroleptic malignant syndrome,” Clinical Pharmacy, vol. 3, no. 3, pp. 302–307, 1984.
[24]
J. M. Davis, S. N. Caroff, and S. C. Mann, “Treatment of neuroleptic malignant syndrome,” Psychiatric Annals, vol. 30, no. 5, pp. 325–331, 2000.
[25]
P. Sakkas, J. M. Davis, P. G. Janicak, and Z. Wang, “Drug treatment of the neuroleptic malignant syndrome,” Psychopharmacology Bulletin, vol. 27, no. 3, pp. 381–384, 1991.
[26]
M. R. Rosenberg and M. Green, “Neuroleptic malignant syndrome: review of response to therapy,” Archives of Internal Medicine, vol. 149, no. 9, pp. 1927–1931, 1989.
[27]
K. Yamagata, K. Onizawa, H. Yusa, T. Wakatsuki, T. Yanagawa, and H. Yoshida, “Risk factors for postoperative delirium in patients undergoing head and neck cancer surgery,” International Journal of Oral and Maxillofacial Surgery, vol. 34, no. 1, pp. 33–36, 2005.
