Successful management of delirium with dexmedetomidine in a patient with haloperidol-induced neuroleptic malignant syndrome:A case report

BACKGROUND We report a case of lorazepam-induced agitated delirium treated with haloperidol,which in turn triggered the onset of neuroleptic malignant syndrome(NMS).The latter condition,a medical emergency,was effectively treated with medical treatment and dexmedetomidine,a versatile and highly selective shortacting alpha-2 adrenergic agonist with sedative-hypnotic and anxiolytic effects.CASE SUMMARY A 65-year-old man with a history of bipolar disorder presented to the emergency department with severe abdominal discomfort after binge eating.During his hospital stay,he received intravenous lorazepam for insomnia.On the next day,he became delirious and was thus treated with seven doses(5 mg each)of haloperidol over a 48 h period.Signs of NMS(hyperthermia,rigidity,myoclonus of upper limbs,impaired consciousness,tachypnea,and dark urine)became apparent and haloperidol was immediately suspended and brisk diuresis was initiated.On intensive care unit admission,he was confused,disoriented,and markedly agitated.Dexmedetomidine infusion was started with the goal of achieving a Richmond Agitation-Sedation Scale score of-1 or 0.NMS was resolved gradually and the patient stabilized,permitting discontinuation of dexmedetomidine after 3 d.CONCLUSION Dexmedetomidine may be clinically helpful for the management of NMS,most likely because of its sympatholytic activity.

CASE REPORT OF NEUROLEPTIC MALIGNANT SYNDROME WITH RISING BLOOD SUGAR

Objective To report one case of neuroleptic malignant syndrome （NMS） with raising blood sugar. Methods The patient was studied clinically with biochemistry, white blood cells, psychiatric symptoms, and creatine phosphokinase （CPK） observations. Results The male patient with a history of taking antipsychot- ics more 30 years and his age of onset was about 20 years. He had severe muscular rigidity, altered consciousness and autonomic disturbance associated with elevation of serum CPK levels （max 3755 U/ L ） and leucocytosis （max 13.3 × 10^9/L）, especially granular leukocytosis（ max 90% ） and lymphocytopenia （rain 8% ）. In addition, high blood sugar emerged along with the variation of white blood cells （ max 9. 0 mmol/L）. Conclusion The manifestations of the patient was in conformity with those of the NMS. The patient had catatonic signs such as mutism, drinking difficulty, etc. and excess of saliva. Developmental observation with CPK and white blood cells is able to reveal the severity level of NMS. Raising blood sugar should be also monitoring item.

Diagnosis and treatment of bipolar disorder in Phelan-McDermid syndrome:A case report and review of literature

BACKGROUND Phelan-McDermid syndrome(PMS)is a rare genetic disorder characterized by intellectual disability,delayed language development,autism spectrum disorders,motor tone abnormalities,and a high risk of psychiatric symptoms,including bipolar disorder.CASE SUMMARY This report presented an 18-year clinical history of a 36-year-old woman with PMS,marked by intellectual disabilities,social withdrawal,and stereotyped behaviors.Diagnosed with bipolar disorder at the age of 18 years old,she encountered significant treatment challenges,including severe adverse reactions to antipsychotic medications in 2022,which led to speech and functional regression.Through rehabilitation and comprehensive therapy,her condition gradually improved.In 2024,after further treatment,her symptoms stabilized,highlighting the complexities and successes of long-term management.CONCLUSION Effective management of PMS requires a thorough clinical history,genetic testing,and long-term supportive care.

Flushing as atypical initial presentation of functional gallbladder neuroendocrine carcinoma: A case report

BACKGROUND Neuroendocrine neoplasms are rarely located in the gallbladder(GB),and carcinoid syndrome is exceedingly rare in patients with GB neuroendocrine neoplasms.CASE SUMMARY We report a case of GB neuroendocrine carcinoma(GB-NEC)in a 65-year-old man,who presented with flushing for 2 mo.Pathological specimens of the flushed skin revealed that mucin was deposited between the collagen bundles in the dermis.Computed tomography and magnetic resonance imaging indicated neoplasm in the GB with liver invasion and enlarged lymph nodes in the portacaval space.High fluorodeoxyglucose uptake was detected in lymph nodes in the portacaval space,but distant metastasis was not seen by positron emission tomography.Ultrasound-guided needle biopsy of the GB neoplasm was suggestive of high-grade NEC.Because of the functional characteristics of poorly differentiated NEC,en bloc cholecystectomy,resection of hepatic segments IVb and V,pancreaticoduodenectomy,and regional lymphadenectomy were performed.A diagnosis of poorly differentiated NEC was made by pathological findings and immunohistochemical staining data.Ki-67 index was>80%.The patient refused adjuvant therapy and passed away in the 7th month.CONCLUSION Distinctive manifestation combined with imaging helps make correct preoperative diagnosis.Radical surgery and adjuvant chemotherapy might improve prognosis.

Human immunodeficiency virus patients with low CD4 counts are more likely to have precancerous polyps identified during index colonoscopy

BACKGROUND Antiretroviral treatment(ART)has improved the life expectancy of patients living with human immunodeficiency virus(HIV).As these patients age,they are at increased risk for developing non-acquired immunodeficiency syndrome defining malignancies(NADMs)such as colon cancers.AIM To determine which factors are associated with the development of precancerous polyps on screening colonoscopy in patients with HIV and to investigate whether HIV disease status,measured by viral load and CD4 count,might influence precancerous polyp development.METHODS A retrospective review of records at two urban academic medical centers was performed for HIV patients who had a screening colonoscopy between 2005-2015.Patients with a history of colorectal cancer or polyps,poor bowel preparation,or inflammatory bowel disease were excluded.Demographic data such as sex,age,race,and body mass index(BMI)as well as information regarding the HIV disease status such as CD4 count,viral load,and medication regimen were collected.Well-controlled patients were defined as those that had viral load<50 copies,and poorly-controlled patients were those with viral load≥50.Patients were also stratified based on their CD4 count,comparing those with a low CD4 count to those with a high CD4 count.Using colonoscopy reports in the medical record,the size,histology,and number of polyps were recorded for each patient.Precancerous polyps included adenomas and proximal serrated polyps.Data was analyzed using Fisher’s exact tests and logistic regression through SAS 3.8 software.RESULTS Two hundred and seven patients met our inclusion criteria.The mean age was 56.13 years,and 58%were males.There were no significant differences in terms of age,race or ethnicity,insurance,and smoking status between patients with CD4 counts above or below 500.BMI was lower in patients with CD4 count<500 as compared to those with count>500(P=0.0276).In patients with CD4>500,53.85%of patients were female,and 70.87%of patients with CD4<500 were male(P=0.0004).Only 1.92%of patients with CD4≥500 had precancerous polyps vs 10.68%of patients with CD4<500(P=0.0102).When controlled for sex,BMI,and ART use,patients with CD4<500 were 9.01 times more likely to have precancerous polyps[95%confidence interval(CI):1.69-47.97;P=0.0100].Patients taking non-nucleoside reverse transcriptase inhibitors were also found to be 10.23 times more likely to have precancerous polyps(95%CI:1.08-97.15;P=0.0428).There was not a significant difference noted in precancerous polyps between those that had viral loads greater or less than 50 copies.CONCLUSION Patients with low CD4 counts were more likely to have precancerous polyps on their screening colonoscopy although the etiology for this association is unclear.We also found an increased risk of precancerous polyps in patients taking non-nucleoside reverse transcriptase inhibitors,which is contradictory to prior literature showing ART has decreased the risk of development of NADMs.However,there have not been studies looking at colorectal cancer and ART by drug class,to our knowledge.Further prospective studies are needed to determine the effect of HIV control and therapies on polyp development.