Recurrence of Neuroleptic Malignant Syndrome With Olanzapine Treatment

Ms. A, a 70-year-old woman with a history of schizoaffective illness, was admitted to our inpatient unit with an acute psychotic-manic episode. Two years and 1 year before this admission, she had been treated for similar episodes with the antipsychotic medications chlorprothixene and then zuclopenthixol HCl; both times this treatment resulted in the symptoms of neuroleptic malignant syndrome. Ms. A had been free of antipsychotic medication for over 6 months. Therefore, treatment with olanzapine, a new atypical antipsychotic medication that was not known to be connected with neuroleptic malignant syndrome, was initiated, 5 mg/day, concurrent with treatment with carbamazepine and betahistine. Because of Ms. A’s extreme restlessness, her dose of olanzapine was increased to 10 mg/day after 2 days. Immediately, a fever of 37.8°C appeared; she had a pulse of 120 bpm and a blood pressure level of 180 mm Hg diastolic and 100 mm Hg systolic. Ms. A’s creatine phosphokinase level was extremely elevated—1,573 U/liter. Ms. A’s parkinsonian symptoms included cogwheel rigidity. Olanzapine treatment was discontinued; Ms. A had a corresponding resolution of her neuroleptic malignant syndrome symptoms over 3 days. Ms. A’s creatine phosphokinase level on the third day was 343 U/liter. Her psychotic symptoms were barely controlled with high doses of benzodiazepines added to her medication regimen.