Neuroleptic Malignant Syndrome From Oxcarbazepine and Topiramate Withdrawal: An Unusual Case

Figures

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  Figure 1. Electrocardiogram on Admission Electrocardiogram showing sinus tachycardia at an approximate heart rate of 150 beats per minute. The correct QT interval by the Bazett formula is 379 milliseconds (within the normal range of 350-450 ms for adult males).

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  Figure 2. CT Pulmonary Angiography of Bilateral Pulmonary Emboli - 2A) Extensive bilateral pulmonary emboli in the left and right pulmonary arteries with near total occlusions represented by contrast filling defects (red circles). Bilateral consolidations can also be seen in the left and right lower lobes (blue circles). - 2B) Evidence of right-sided heart strain is demonstrated by dilatation of the pulmonary trunk to 2.99 cm (yellow line).

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  Figure 3. Pharmacologic Agents Most Commonly Associated with NMS from FAERS (From 1968 to June 30, 2021) Figure depicting the most common attributable generic medications to NMS with statistical data collected by the FDA Adverse Event Reporting System (FAERS) from 1968 to June 30, 2021 [2]. The data collection method was done using the following steps on the FAERS website: 1) Searched by reaction term using "Neuroleptic Malignant Syndrome", 2) filtered report of cases by generic names, 3) filter received years to include 1968 to 2021. Of note, the medications are combined under the same generic name for different formulations and administration routes ([olanzapine + olanzapine pamoate]; [haloperidol + haloperidol lactate + haloperidol decanoate]; [quetiapine + quetiapine fumarate]; [aripiprazole + aripiprazole lauroxil]; [lithium + acetate, aspartate, carbonate, citrate, sulfate]; [valproic acid + valproate sodium + divalproex sodium] (Abbreviations: FDA: Food Drug Administration, FAERS: FDA Adverse Event Reporting System; NMS: neuroleptic malignant syndrome) Adapted from [2]

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  Figure 4. Basal Ganglia Motor Regulatory Functions Figure illustrating the normal pathway of dopaminergic potentiation upon the basal ganglia leading to modulation of cortical motor activity. A deprivation in D2 activity will lead to overt activation of the indirect inhibitory pathway causing decreased movement, involuntary hypertonia, and rigid muscle. Synergistically, a lack of D1 activity in the direct excitatory pathway will also promote decreased movement and rigidity. The cortical structures are represented by color-coded locations and the included figure legends identify the structures accordingly. (Abbreviations: SNpc: substantia nigra pars compacta, GPi: globus pallidus interna, GPe: globus pallidus externa, STN: subthalamic nuclei, GABA: gamma-aminobutyric acid, D1: dopamine-1 receptor, D2: dopamine-2 receptor)