Expansion
FEVER: Fever, Encephalopathy, Vitals unstable, Elevated CK, Rigidity
Expansion
FEVER:
- F - Fever, often above 40 degrees
- E - Encephalopathy: confusion, fluctuating consciousness
- V - Vitals unstable: labile blood pressure, tachycardia, sweating
- E - Elevated creatine kinase, often markedly, with a leucocytosis
- R - Rigidity, lead pipe and generalised
Onset is over days to weeks, usually within two weeks of starting or increasing a dopamine antagonist.
Two mechanisms, both reducing dopamine
- Starting or increasing an antipsychotic, or an antiemetic such as metoclopramide or prochlorperazine
- Abruptly stopping a dopamine agonist, classically levodopa in Parkinson’s disease. This is the presentation most often missed
Treatment: stop the causative drug or restart the withdrawn dopaminergic agent, fluids, active cooling, benzodiazepines, and dantrolene or bromocriptine in severe cases.
Complications: rhabdomyolysis with acute kidney injury, DIC, aspiration, venous thromboembolism and respiratory failure. Mortality remains around 10 per cent.
Restarting an antipsychotic is possible after at least two weeks, using a different and preferably lower potency agent, at low dose with close monitoring.