Rohail Muhammad U, Khan Ayub, Pflaum Rhani M, Patel Mitul, Moody Melissa A
Medical School, West Virginia School of Osteopathic Medicine, Lewisburg, USA.
Psychiatry, Boone Memorial Health, Madison, USA.
Cureus. 2023 Mar 15;15(3):e36178. doi: 10.7759/cureus.36178. eCollection 2023 Mar.
A 29-year-old male presented to the emergency department with complaints of shortness of breath and numbness in bilateral upper and lower extremities that started a few hours prior to arrival. On physical examination, the patient was afebrile, disoriented, tachypneic, tachycardic, and hypertensive with generalized muscle rigidity. Further investigation revealed that the patient had recently been prescribed ciprofloxacin and restarted on quetiapine. The initial differential diagnosis was acute dystonia, and subsequently, the patient was placed on fluids, lorazepam, diazepam, and later benztropine. The patient's symptoms began to resolve, and psychiatry was consulted. Given the patient's autonomic instability, altered mental status, muscle rigidity, and leukocytosis, psychiatric consultation revealed an atypical case of neuroleptic malignant syndrome (NMS). It was postulated that the patient's NMS was caused by a drug-drug interaction (DDI) between ciprofloxacin, a moderate cytochrome P450 (CYP) 3A4 inhibitor, and quetiapine, which is primarily metabolized by CYP3A4. The patient was then taken off quetiapine, admitted overnight, and discharged the next morning with complete resolution of his symptoms along with a prescription for diazepam. This case highlights the variable presentation of NMS and the need for clinicians to consider DDI when managing psychiatric patients.
一名29岁男性因在就诊前数小时开始出现呼吸急促以及双侧上下肢麻木而前往急诊科。体格检查发现，患者无发热，神志不清，呼吸急促，心动过速，血压升高，伴有全身肌肉僵硬。进一步调查发现，该患者最近被开了环丙沙星，并重新开始服用喹硫平。初步鉴别诊断为急性肌张力障碍，随后，患者接受了补液治疗，并使用了劳拉西泮、地西泮，之后又使用了苯海索。患者的症状开始缓解，并咨询了精神科。鉴于患者存在自主神经不稳定、精神状态改变、肌肉僵硬和白细胞增多，精神科会诊发现这是一例非典型的抗精神病药恶性综合征（NMS）。据推测，患者的NMS是由环丙沙星（一种中度细胞色素P450（CYP）3A4抑制剂）与主要由CYP3A4代谢的喹硫平之间的药物相互作用（DDI）引起的。然后让患者停用喹硫平，住院过夜，第二天早上出院，其症状完全缓解，并开具了地西泮处方。该病例突出了NMS的多样表现以及临床医生在管理精神科患者时考虑药物相互作用的必要性。
