Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

  • * death

  • * life-threatening

  • * hospitalisation

  • * disability

  • * congenital anomaly

  • * other medically important event

An 87-year-old woman developed neuroleptic malignant syndrome (MNS) following sudden withdrawal of levodopa.

The woman was hospitalised after two falls with no obvious causes. At that time, she was receiving treatment with fosfomycin for voiding disorder. She had a history of parkinsonism probably of vascular origin with no current treatment, and also had arterial hypertension. She also had arterial fibrillation, for which she was on unspecified anticoagulation. Her baseline Barthel score was 100 with no cognitive deterioration. On admission, she was diagnosed with respiratory infection and urinary tract infection (aetiology unknown). Twenty-four hours after the admission, her condition clinically worsened with fever and muscle rigidity, and she was found to be disconnected from the surroundings. Laboratory tests revealed creatinine level of 1.9 mg/dL and creatine kinase level of 12863 IU/L. She also developed rhabdomyolysis. Her family was asked whether, she had been receiving any treatments especially for her walking disorder (parkinsonism). It was noted that, she was receiving levodopa [L-dopa; route and dosage not stated] for parkinsonism prior to the admission, and had not received it since the admission. She was suspected to have MNS related to levodopa withdrawal, and was admitted to the ICU. Twenty days later, she was transferred to the ward with a diagnosis of MNS related to sudden levodopa withdrawal, which was further complicated with rhabdomyolysis-induced acute kidney injury. She also developed respiratory insufficiency related to respiratory infection. Thereafter, she developed recurrent atelectasis of lungs and anaemisation, and received RBC concentrates. After transfer to the ICU, reverse right shoulder dislocation was observed, following which reduction in anaesthesia was required. She also had faecal impaction and self-limiting epistaxis.

The woman further presented with severe functional deterioration, which included requirement of assistance for all basic activities of daily living, physical help to walk and use stairs, with mixed incontinence, and mental deterioration, which included frequent forgetfulness. After a good response to rehabilitation, she was transferred for functional recovery. After six months, her functional and mental deterioration persisted.

Author comment: "In conclusion, we noted the sudden withdrawal of dopaminergics as the cause of [neuroleptic malignant syndrome] and how the comprehensive assessment of patients aids its diagnosis and management." "She was ... diagnosed with MNS after the withdrawal of [levodopa]".