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Neuroleptic malignant syndrome induced by low dose aripiprazole in first episode psychosis.

Neuroleptic malignant syndrome (NMS) is an idiosyncratic reaction that is potentially life threatening, especially if it is not recognized and treated early. NMS develops on exposure to antipsychotic medications. The incidence of NMS has been reported to be 0.02%–2.44%,1 with the majority of cases occurring in individuals between 18 and 59 years of age.2 The underlying mechanism for the development of NMS is unclear; however, it is believed to be related to rapid dopamine (D2) blockade by antipsychotics. Of patients who develop NMS, 66% have been reported to have onset of NMS symptoms within 2 weeks after starting an antipsychotic medication.3 In some patients, prodromal symptoms may become apparent within hours of initiating antipsychotic medication. The full syndrome develops in approximately 3–5 days.2 The classic triad involves the autonomic nervous system, the extrapyramidal system, and cognitive changes. Proposed research criteria for NMS listed in the Diagnostic and Statistical Manual for Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) involve severe muscle rigidity and hyperthermia along with two other criteria, including altered mental status, elevated creatine phosphokinase (CPK), elevated white blood cell count, incontinence, diaphoresis, tremor, mutism, tachycardia, labile blood pressure, and dysphagia, that develop in association with treatment with antipsychotic medication.4 NMS is seen less frequently with second generation (atypical) antipsychotics than with conventional antipsychotics.5 Aripiprazole is a relatively new antipsychotic with a unique mechanism of action involving partial agonism with high affinity at dopamine D2 and serotonin 5-HT1A receptors as well as antagonism at serotonin 5-HT2A receptors.5 It has been shown to be effective in the treatment of schizophrenia and bipolar disorder, with antipsychotic and antimanic properties superior to placebo at dose ranges of 10–30 mg/day. The case described here involved a patient with first episode psychosis who developed NMS on a low dose of aripiprazole.