NMS... Ack!

[Hurricane]

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I think my Zyprexa gave my little teenage patient NMS. But even worse than my medicine doing this bad thing, the primary team didn't believe me, so I had to keep going up there to argue that my medicine did this bad thing. Finally they talked to a toxicologist (?) who agreed, and they finally took it seriously and did some of the stuff I was recommending. But cripes.

OK so she wasn't rigid but she was febrile all day with HR in the 150s and delirious with elevated CK and she just looked bad and was getting worse by the hour. And there are cases of atypical NMS without rigidity that are more common with the atypicals.

I dunno... where I went to med school, there was an attending who is kinda big in the NMS field, so whenever there was even a whisper the possibility of NMS, the patient was whisked away to the ICU. So maybe I'm just too hypervigilant. But if I was the resident covering that floor, I wouldn't want her there like that. They did kinda perk up when I said it was fatal though.

So, stressful day. But more so for my patient. 🙁

 

[michaelrack]

how high was the fever and the ck?

 

[Faebinder]

This is not the first time I heard of psychiatry vs IM when it comes to atypical NMS in a child. The previous case actually ended up with a dead child cause the pediatrician insisted on D/C-ing psychiatry orders.

I am glad you insisted on your assessment.

I think the key in the diagnosis is the elevated CK. I also hear of muscle fasiculations even when there is no rigidity.

 

[whopper]

This is not the first time I heard of psychiatry vs IM when it comes to atypical NMS in a child.

I have never had a patient with NMS. I don't know if that's a good thing or bad thing becuase if I ever get one, and I figure at some point it'll happen in the future, I'll be just as inexperienced as a first year resident on day 1.

And I can imagine that if NMS happened in inpatient, its going to be a lot of turfing & arguing, possibly even lacking of doctors taking responsibility & trying to push it on the other doctor if it boiled down to a psychiatry vs IM situation.

There's a patient at a hospital I'm doing an elective at that may have had NMS. He didn't have all the criteria for it, & like above, there's a debate going on between the psychiatrist & the IM doc. The psychiatrists doesn't believe its NMS, the IM doc is convinced it is.

 

[michaelrack]

There is a range of antipsychotic side effects, from simple EPS (including rigidity, parkinsonism, akathisia) to NMS (fever, elevated ck, delirium, rigidity, leukocytosis). I am rather a purist when it comes to NMS, and don't like to call an atypical case NMS. However, patients don't always fit at one end of the spectrum, and you have to do what's best for your patient even if they don't meet classical criteria for NMS.

"And I can imagine that if NMS happened in inpatient, its going to be a lot of turfing & arguing, possibly even lacking of doctors taking responsibility & trying to push it on the other doctor if it boiled down to a psychiatry vs IM situation."

The typical scenario I have seen is that a patient with classical NMS is transferred by the local medical doctor to a university internal medicine inpatient service. The IM service then tries to dump the patient on psychiatry as soon as the fever is less than 100, even though the patient is usually still confused and incontinent.

 

[Hurricane]

how high was the fever and the ck?

On Friday it was 38.5 and 809, which admittedly wasn't that high, but her pulse had been in the 140s-150s all day, and I just had a feeling that she looked bad and was going to get worse, and nobody seemed too concerned, which made me worried. So I insisted they check it again, and it went up to 39 and 1800s. At that point I think they tried to send her to the ICU but they didn't have a bed, so they managed her on the floor. I wasn't there over the weekend, but they called the resident on-call and said she was rigid, but the description sounded more like posturing. Now her vitals, temp and CK are down, but she looks catatonic.

My attending gave me an article about various types of catatonia, and in retrospect she may have had some kind of excited catatonia to begin with, which I didn't recognize because I had only seen the regular non-excited kind before (I was with a different attending the first day I saw her). If that's the case we probably should have given her a benzo in the first place. She's on ativan now, and no longer agitated, but still catatonic, and they had to put in a feeding tube. As far as other medical causes, she originally presented with conversion d/o, and already had the million dollar medical/neuro/ID workup, all negative. She's a mystery...

And in the article above they also talk about a "malignant catatonia" so perhaps she had that. I dunno, but I hope she responds to the benzos because she's too young to legally get ECT in Texas.

 

[MBK2003]

And in the article above they also talk about a "malignant catatonia" so perhaps she had that. I dunno, but I hope she responds to the benzos because she's too young to legally get ECT in Texas.

Sadly, though ECT is usually the fastest and most effective treatment for lethal/malignant catatonia. In the past I've use the NMS Information Service (www.nmsis.org) hotline service to get help and references when we've suspected malignant catatonia.

 

[Hurricane]

Sadly, though ECT is usually the fastest and most effective treatment for lethal/malignant catatonia. In the past I've use the NMS Information Service (www.nmsis.org) hotline service to get help and references when we've suspected malignant catatonia.

Was that helpful? I was considering calling it the other day...

 

[Hurricane]

Well, I called the NMS hotline today because although she was a little bit better with the benzos and supportive care for a while, she was worse today - febrile, HR in 170s, CK went back up a little, and now has more rigidity. The doc I talked to was very knowledgeable and helpful. She's getting bromocriptine now, and she'll get dantrolene if the primary team attending ok's it. If that doesn't work, then I guess the next option is sending her out of state for ECT (which apparently they've done in the past for refractory catatonia - stupid texas law). 🙁