Neuroleptic malignant syndrome without withdrawal of levodopa.

Neuroleptic malignant syndrome (NMS) in patients with Parkinson disease is a rare but potentially lethal complication. The withdrawal of levodopa is the most common cause of NMS. Other precipitating factors include hot weather, dehydration, infection, menstruation, etc. 1 Only 21 patients with Parkinson disease who developed NMS without any history of withdrawal of levodopa have been reported in the literature. We encountered a similar patient who developed NMS without withdrawal of levodopa, following an episode of acute gastroenteritis and dehydration. This 42-year-old man with a 7-year history of Parkinson disease presented with a history of acute diarrhoea for 4 days, followed 2 days later by high grade fever. On day 4, the patient developed weakness and rigidity of all 4 limbs and decrease in urine output. He was on levodopa and carbidopa till the day of admission. He had a history of dyskinesias after taking drugs and also of ‘wearing off’ effect. The patient was conscious, oriented but drowsy at the time of admission; the blood pressure was 180/80 mmHg, pulse rate 94/minute and the body temperature was 102 o F. He had rigidity on examination and the systemic examination was normal. On laboratory examination, haemoglobin was 11.5 g/dl, total leucocyte count 11 400/cmm, platelets 180 000/cmm, blood urea 204 mg/dl, creatinine 10.4 mg/dl, potassium 5.2 mEq/L, calcium 4.7 mg/dl, phosphate 7.9 mg/dl and total creatine phosphokinase 1630 IU/L. Urine was positive for myoglobin. We made a diagnosis of NMS with acute renal failure and Parkinson disease. He was treated with intravenous fluids, furosemide, bromocriptine and haemodialysis; carbidopa and levodopa were continued. He died on day 4 after admission. Discussion