J Korean Med Sci.  2008 Aug;23(4):734-736. 10.3346/jkms.2008.23.4.734.

Probable Case of Neuroleptic Malignant Syndrome Following Administration of Antituberculotic Drugs in a Chlorpromazine-Treated Patient

• Shim G
• Kang DH
• Kwon JS

• KMID: 1785840
• DOI: http://doi.org/10.3346/jkms.2008.23.4.734

Abstract

Neuroleptic malignant syndrome (NMS), a potentially fatal adverse reaction to neuroleptics, is known to occur more often in the initial stage of antipsychotic treatment. We describe a patient with chronic schizophrenia who, in a few days after the addition of antituberculotic drugs to his antipsychotic regimen, developed probable NMS without pyrexia. We reasoned that rifampin, a strong hepatic enzyme inducer, decreased the plasma chlorpromazine concentration of the patient, with the result of cholinergic hyperactivity and finally, the symptoms of NMS. Therefore, physicians should be aware of drug interactions and the likelihood of NMS, and consider antipsychotic dose adjustment when prescribing drugs that may influence pharmacokinetic properties of antipsychotics in a patient with schizophrenia receiving long-term antipsychotic treatment.

Keyword

Neuroleptic Malignant Syndrome; Rifampin; Chlorpromazine

MeSH Terms

Adult
Antitubercular Agents/*adverse effects
Chlorpromazine/*adverse effects
Creatine Kinase/blood
Drug Interactions
Enzyme Induction/drug effects
Humans
Male
Neuroleptic Malignant Syndrome/*etiology
Rifampin/*adverse effects
Schizophrenia/*drug therapy

Reference

1. Levenson JL. Neuroleptic malignant syndrome. Am J Psychiatry. 1985. 142:1137–1145.

2. Caroff SN, Mann SC. Neuroleptic malignant syndrome. Med Clin North Am. 1993. 77:185–202.

3. Hynes AF, Vickar EL. Case study: neuroleptic malignant syndrome without pyrexia. J Am Acad Child Adolesc Psychiatry. 1996. 35:959–962.

4. Rodriguez OP, Dowell MS. A case report of neuroleptic malignant syndrome without fever in a patient given aripiprazole. J Okla State Med Assoc. 2006. 99:435–438.

5. Totten VY, Hirschenstein E, Hew P. Neuroleptic malignant syndrome presenting without initial fever: a case report. J Emerg Med. 1994. 12:43–47.

6. Woodbury MM, Woodbury MA. Neuroleptic-induced catatonia as a stage in the progression toward neuroleptic malignant syndrome. J Am Acad Child Adolesc Psychiatry. 1992. 31:1161–1164.

7. Gorski JC, Vannaprasaht S, Hamman MA, Ambrosius WT, Bruce MA, Haehner-Daniels B, Hall SD. The effect of age, sex, and rifampin administration on intestinal and hepatic cytochrome P450 3A activity. Clin Pharmacol Ther. 2003. 74:275–287.

8. Kim YH, Cha IJ, Shim JC, Shin JG, Yoon YR, Kim YK, Kim JI, Park GH, Jang IJ, Woo JI, Shin SG. Effect of rifampin on the plasma concentration and the clinical effect of haloperidol concomitantly administered to schizophrenic patients. J Clin Psychopharmacol. 1996. 16:247–252.

9. Margetic B, Aukst-Margetic B. Neuroleptic malignant syndrome and clozapine withdrawal at the same time? Prog Neuropsychopharmacol Biol Psychiatry. 2005. 29:145–147.

10. Spivak B, Gonen N, Mester R, Averbuch E, Adlersberg S, Weizman A. Neuroleptic malignant syndrome associated with abrupt withdrawal of anticholinergic agents. Int Clin Psychopharmacol. 1996. 11:207–209.

11. Choi RL, Roth RH. Development of supersensitivities of apomorphine induced increases in acetylcholine levels and stereotype after chronic fluphenazine treatment. Neuropharmacology. 1978. 17:59–64.

12. Amore M, Zazzeri N. Neuroleptic malignant syndrome after neuroleptic discontinuation. Prog Neuropsychopharmacol Biol Psychiatry. 1995. 19:1323–1334.