恶性综合征临床误诊分析

Analysis of Causes of Clinical Misdiagnosis in Neuroleptic Malignant Syndrome

目的探讨恶性综合征误诊原因及防范措施。方法在中国知网中国期刊全文数据库、中国科技期刊全文数据库及万方数据库检索并搜集恶性综合征55例,加上我科收治的1例,回顾性分析其临床资料。结果典型及非典型抗精神病药物均有引起恶性综合征的风险,最常见药物为奥氮平、利培酮,其次为氯氮平。13例无药物变动,43例存在药物调整。43例调整药物后出现恶性综合征时间为1 d^6个月,13例无药物变动出现恶性综合征时间为6.5个月~3年。临床常见表现为发热、肌强直和意识障碍,分别占89.29%、71.43%及60.07%。30例首诊误诊,误诊时间为3 d^1个月,平均8.5 d,误诊为感染性疾病15例,误诊为精神疾病加重6例,误诊为脑血管病3例,误诊为药物性肝损伤、横纹肌溶解、癫痫发作各2例,误诊率53.57%。所有患者均依据Levenson恶性综合征诊断标准确诊为恶性综合征,52例停用当前抗精神病药物,4例停用多巴丝肼再度加用多巴丝肼,12例给予溴隐亭,6例给予左旋多巴,5例进行血液透析,6例进行有创机械通气,同时给予抗感染治疗29例。6例死亡,病死率10.71%。结论恶性综合征临床罕见且病死率高,涉及药物广泛,临床表现无特异性,误漏诊率高,早期诊断并及时干预是改善预后的关键。

Objective To investigate the causes of misdiagnosis and preventive measures of neuroleptic malignant syndrome(NMS).Methods Fifty-six cases of NMS were collected including 55 cases retrieved in China journal full text database,China science and technology journal full text database and Wanfang database and 1 case diagnosed in our department.We retrospectively analyzed the clinical data of the above cases and the causes of misdiagnosis.Results Both typical and atypical antipsychotics can cause NMS,among which Olanzapine and Risperidone were the most common,followed by Clozapine.Antipsychotics were adjusted recently in 43 cases,and no treatment adjusted in 13 cases.The shortest and the longest time interval from antipsychotics treatment adjustment in 43 cases to development of NMS was 1 day and 6 months respectively.The shortest and the longest time interval from antipsychotics treatment in 13 cases to development of NMS was 6.5 months and 3 years.The most common clinical manifestations included fever and myotonia,followed by disturbance of consciousness,accounting for 89.29%,71.43%and 60.07%respectively.Thirty cases were misdiagnosed at initial visit,and the duration of misdiagnosis was 3 days-one month,respectively,with an average of 8.5 days.Fifteen cases were misdiagnosed as infectious disease,6 cases as mental illness aggravation,3 cases as cerebrovascular disease,2 cases as drug-induced liver injury,rhabdomyolysis and epilepsy respectively,with a misdiagnosis rate of 53.57%.All patients were diagnosed as NMS according to diagnostic criteria for Levenson malignant syndrome(NMS).After diagnosis,52 patients stopped taking current antipsychotics,4 cases stopped dopaserizide which was then readministered,12 cases were given bromocriptine,and 6 cases were given levodopa.Madopar were prescribed again when NMS was diagnosed in the cases after madopar was withdrawn.Five cases underwent hemodialysis,6 cases were given invasive mechanical ventilation.Meanwhile,29 cases were given anti-infection treatment.Consequently,6 cases died,and the fatality rate was 10.71%.Conclusion NMS is rare but fatal with high mortality rate,and a wide range of drugs can be involved.The clinical symptoms are non-specific,which leads to high misdiagnosis rate.Early detection and timely intervention is crucial for the prognosis of NMS.