Dados do Trabalho

Título

NEUROLEPTIC MALIGNANT SYNDROME FOLLOWING THE INITIATION OF ARIPIPRAZOLE IN A PATIENT WITH A NEURODEVELOPMENTAL DISORDER WITH INVOLUNTARY MOVEMENTS ASSOCIATED WITH A GNAO1 GENE MUTATION

Apresentação do caso único

A 10-year-old female patient with global developmental delay began treatment with a full dose of aripiprazole 10 mg/day for psychomotor agitation. On the first day, she developed somnolence and fever. By the third day, muscle rigidity appeared, and by the fourth day, she had persistent fever, anuria and somnolence. She was admitted to the intensive care unit under continuous sedation, with renal failure, hyperkalemia, metabolic acidosis, and hypernatremia. Initial lab tests showed a significant increase in transaminases , acute renal failure classified as KDIGO 3, and elevated creatine phosphokinase levels above 42,670 U/L. Given her symptoms and the timing and dose of aripiprazole initiation, neuroleptic malignant syndrome (NMS) was diagnosed. The medication was immediately discontinued. The patient underwent continuous dialysis and was treated with dantrolene and benzodiazepines, leading to clinical and laboratory improvement. After stabilization, she was extubated, and choreiform movements were observed. Further investigation, including CSF analysis, brain MRI, and genetic testing, revealed a mutation in the GNAO1 gene, diagnosing a neurodevelopmental disorder with involuntary movements. Gabapentin, clonidine, clonazepam, and topiramate were prescribed for movement disorder management. Due to refractory choreic movements, a deep brain stimulation (DBS) device was implanted bilaterally in the globus pallidus.

Discussão

NMS is a rare, potentially fatal adverse reaction antipsychotics, characterized by muscle rigidity, fever, altered consciousness, and autonomic dysfunction. Risk factors include treatment initiation, dosage changes, high doses, parenteral administration, and polypharmacy. Management involves immediate discontinuation of the antipsychotic and supportive care. Treatment options include benzodiazepines, bromocriptine, dantrolene and electroconvulsive therapy (ECT), for severe cases. The investigation during the hospital stay resulted in the diagnosis of a neurodevelopmental disorder with involuntary movements associated with the GNAO1 mutation. The clinical phenotype of developmental delay, hypotonia, and hyperkinetic movement disorders should raise suspicion for GNAO1-related conditions in pediatric patients.

Comentários finais

This report highlights a severe, rare complication from atypical antipsychotic use in a child, emphasizing the need for early detection of adverse events and careful risk-benefit analysis in pediatric patients.

Referências

BELVEDERI MURRI, M. et al. Second-Generation Antipsychotics and Neuroleptic Malignant Syndrome: Systematic Review and Case Report Analysis. Drugs in R&D, v. 15, n. 1, p. 45–62, 13 jan. 2015.

BERLOFFA, S. et al. Neuroleptic Malignant Syndrome in Children with Autism Spectrum Disorder (ASD): A Case Report and Brief Review of Recent Literature. Children, v. 8, n. 12, p. 1201, 18 dez. 2021.

TORMOEHLEN, L. M.; RUSYNIAK, D. E. Neuroleptic malignant syndrome and serotonin syndrome. Thermoregulation: From Basic Neuroscience to Clinical Neurology, Part II, v. 157, p. 663–675, 2018.

TSE, L. et al. Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Perspective. Current Neuropharmacology, v. 13, n. 3, p. 395–406, 14 jul. 2015.

VIROLLE, J. et al. What clinical analysis of antipsychotic-induced catatonia and neuroleptic malignant syndrome tells us about the links between these two syndromes: A systematic review. Schizophrenia research, v. 262, p. 184–200, 1 dez. 2023.

Palavras Chave

Movement disorder; antipsychotics; neuroleptic malignant syndrome