Objective: To present clinical feature Neuroleptic Malignant Syndrome (NMS) in Toxoplasma cerebri, a rare case.

Background: Neuroleptic malignant syndrome (NMS) is a rare case, life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. It has been associated with virtually all neuroleptics, including newer atypical antipsychotics, as well as a variety of other medications that affect central dopaminergic neurotransmission. Even Mortality and morbidity attributed to this syndrome have recently declined markedly due to greater awareness, earlier diagnosis, and intensive care intervention but early detection is important. Ballismus is a rare symptom of Neuroleptic malignant syndrome (NMS). This case demonstrated that Ballism could exactly occur as major and early manifestation in a patient with Neuroleptic Malignant Syndrome (NMS).

Methods: Case report.

Results: A 34-year old male with gradual decrease of consciousness since 2 weeks before admission, accompanied by headache, fever, nausea and vomiting. Initial examination revealed Glasgow Coma Scale (GCS) score of 6/15 with meningeal sign without lateralization. Toxoplasma serology revealed raised IgG antibody levels of >650 U/ml, patient also tested positive for HIV with CD4 cell count was 61/microlitre, with Head CT scan contrast revealed encephalitis and abcess cerebrii at late capsule phase. At 12th daycare, patient was anxious and got therapy haloperidol 1 mg/day, then doses was incresead 2 mg/day and then at 2 weeks later occurred ballism. Haloperidol doses still increased 4,5 mg/day and then occurred malignant hipertermia with axillary temperature 42°C which unresponsive to antipyretic medication and increases of CPK (8472 u/L). Second Head CT-Scan Contrast revealed ameliorate process. All clinical criteria was complied for Neuroleptic malignant syndrome (NMS), then haloperidol drug was stopped, the patient gave agresif rehydration protocol,and clonazepam 2mg OD at night as long as 2 weeks. Ballism and hyperthermia gradually decreased and then ceased after 2 weeks of daycare from the established diagnosed of NMS.

Conclusions: Our case highlights ballism could be the first presenting sign of NMS other than stereotypical clinical presentation of NMS including high fever, muscle rigidity and dysautonomia. Early detection of NMS is very important to prevent potentially life-threatening effect.

References: 1. Ramadhan O, Ian F.P, Bernt A.E, et al. Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatr Dis Treat. 2017;13:161-175. 2. Lurdes T, Alasdair B, Vanessa S, et al. Neuroleptic malignant syndrome. A review from a clinically oriented perspective. Curr Neuropharmacol 2015; 13(3):395-406.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/ballism-as-major-manifestation-in-neuroleptic-malignant-syndrome-in-a-patient-toxoplasmosis-cerebri/