i made this presentation,this is an original case of NMS.

1. Case
Presentation
By : Dr. Duaa
(PGR-1)

2. • Fever for 1 week
• Altered level of conscious for 1 week
• Generalised weakness for 10 days
• Inability to swallow solid and liquids diet.
A 75 year old man labour by profession ,resident
of Karachi with no known co-morbids presents in
emergency room with complaint of:

3. HOPC:
According to my Pt’s attendant ,he was in usual state of health 15 days
back and used to do all his work on his own ,then he developed
generalised weakness i-e he was unable to walk and perform his daily
chores it was gradual in onset and constant in nature and was
associated with memory loss (could not recall present events and could
not recognise family members and relatives ) there were no relieving
and aggravating factors.After 2-3 days he was unable to swallow food
and even water ,he was feeling like there is some kind of band in his
neck .

4. • He then developed fever of 100F continuous in nature associated
with sweating and mild headache .He did not have cough , nausea
and vomiting. He was taken to a local hospital but then they referred
him to ZUH.

5. Medical history
• Histotory of RTA in 2021 (managed conservatively and pt resumed his daily
activities.
• Hostory of memory loss (2-3 months back )
1. Recalling past events happened 40-50 yrs back
2. Having trouble recalling things happening in present
Sometimes unable to recognise relatives and close ones.
• Went to a hospital for treatment on his own and started the given
treatment.
• Surgical history
• History of left inguinal hernia repair

6. Drug history:
• Doctor prescribed him:
• Quetiapine
• Procyclidine
• sodium valproate
• Fluphenazine
• Haloperidol

7. Family history:
• He was married and has 3 sons and 1 daughter.
• No history of DM, HTN,thyroid,Autoimmune ,Bleeding disorder,psychiatric
illness.
•Personal history:
Dec Oral intake
Dec sleep (takes pills )
No weight loss
He is non smoker and does not do any drugs and has no addiction.
No history of allergy.

8. Social history:
• He was a retired clerk and resident of karachi.
• Living in a 4 room well ventilated house with his family (6 family
members ) and drinks tap water.

9. Nervous system:
• Headache+ve
• Weakness+ve
• Blackouts+ve
• Dizziness+ve
• Paresthesia-ve
• Seizures -veve

10. Respiratory:
• Cough
• Sputum
• Hemoptysis
• Dyspnea. -ve
• Wheezing
• Chest pain

11. Cardiovascular:
• Palpitations -ve
• Chest pain on exertion -ve
• Dyspnea -ve
• Orthopnea -ve
• Paroxysmal noct.dyspnea –ve
• Edema +ve

12. GIT/Abdomen Genitourinary
• Frequency
• Urgency
• Nocturia
• Dysuria. -ve
• Retention
• Hesitency
• Incontinence
• Abdominal pain
• Nausea
• Vomiting
• Heart burn
• Dysphagia
• Diarhea
• Constipation
• Haematemesis

13. Haematological:
• Gum bleeding
• Bruises -ve
• Epistaxis

14. Musculoskeletal:
• Decreased range of motion
• No any deformity
• Dec strength of muscle grip
• Muscle fatigue
• Numbness-ve
• Burning
• Pain-ve
• Tingling-ve

15. Endocrine:
• Excessive sweating
• Heat/cold intolerance. -ve
• Tremors
• Excessive thirst

16. Examination:
• A 75 year old man with average height and weight (BMI of 18.2) lying
on bed.
• He was drowsy , not arrousable.
Vitals:
• BP :130/80 mmhg
• Pulse: 102 b/min
• Temp: 38C
• R/R: 20 breaths/min
• O2 saturation: 98% at room air.

17. General physical examination:
• Anemia -ve
• Jaundice -ve
• Edema +ve (B/L PEDAL EDEMA)
• Dehydration +ve
• Clubbing -ve
• Cyanosis -ve
• Koilonychia –ve
• Old scar marks on forhead.+ve
• Rash -ve

18. Systemic examination:
Neurological examination:
GCS : 6/15 (E2,V1,M3) Pt was drowsy, not arousable, not responding to verbal commands, flexing limbs on noxious stimulus.
Motor examination:
RUL. LUL. RLL. LLL
Bulk: N. N. N. N
Tone: Inc. Inc. Inc. Inc
Power: power could not be assesed because the pt. was unconcious.
Reflexes: Reflexes(Deep tendon) were present.
Planters: B/L Downgoing
Eyes: Eyes were closed. Upon opening they were looking in same direction , moving with the head on checking tge doll’s eye reflex.
Neck: Neck was rigid in all directions.
Kerning sign-ve , Brudzinki sign-ve
Pupils: 4 mm normal in size and B/L reactive to light.
Corneal reflex: present
Gag reflex Present
Cough reflex Present

19. • Respiratory examination:
Inspection: A/P diameter > transverse diameter, Respiratory rate of 20
/min,relaxed and even.
Palpation: chest expansion symetric, tactile fremitus equal bilaterally.No
tenderness to palpation. No lumps or lesions .
Percussion: Percussion note was resonant over lung fields
Ausculation: vesicular breath sounds clear over lung fields. No added sounds
were found.
Cardiovascular examination:S1, S2 were audible on auscultation.no murmurs
.

20. Abdominal examination:
• Abdomen was flat and symmetrical
• Umblicus was centrally placed and flat.
• There were no scar marks and no dilated veins around umblicus.
• It was soft and non tender on palpation
• No visceromegaly was palpable
• and bowel sounds were audible (3/min).

21. Lymph node examination:
• Cervical, axillary and inguinal lymphnodes were not palpable.

22. Differential Diagnosis ?

23. • Encephalitis
• Neuroleptic malignant syndrome
• Serotonin syndrome
• Sepsis
• Heat stroke
• Malignant hyperthermia
• Meningitis
• Cereberal malaria

24. CBC: UCE:
Hb 12.9. Urea 46
PCV/MCV. 38.4/94.4. Creatinine 0.5
TLC. 10.7. Serum sodium. 138
NEUTROPHILS. 86%. Serum potassium 3.8
LYMPHOS. 10%. Serum chloride 107
EOSINO. 0
MONOCYTES. 02
PLATELETS. 227*(10*9)
LAB INVESTIGATIONS:

25. LFTS: RBS: PT/INR,
APTT
Total Bil. 0.51
Direct Bil. 0.05
SGPT. 23U/L
SGOT. 38 U/L
GGT. 54 U/L
Alk. Phosphatase. 50 U/L
Glucose Random: 150
mg/dl
PT 12.1
INR. 1.10
APTT. 33

26. CRP: ESR:
51.8mg/dl 80mm/1st
hr.

27. Physical:
Color yellow
Vol. 50ml
Appearanceturbid
Chemical:
Specific
gravity1.020
Reaction ph.5.0
Protein1+
Glucose negative
Ketone bodies
negative
Bilirubin negative
Urobilinogen
normal
Microscopic:
Leucocytes:03
Red blood
cells:>25
Epithelial cells:02
Bacteria
occasional
Crystals
Amorphous
urates:+1

28. ABG: PH.
7.445
PO2
. 79.6
PCO2.
35.4
HCO3.
23.8
Na.
142
K.
3.59
Cl
101

29. CSF DR: Chemical
examination
Microscopic
examination
Color-
colorless
PROTEIN
26mg/dl
RBC.
2/cumm
WBC
5/cumm
Appearance
Clear
GLUCOSE
65 mg/dl

30. HBsAg 0.24 Ca. 9.1
mg/dl
ANTI HCV 0.245 Phosphorus
2.5 mg/dl
CPK 2064 Mg
2.2 mg/dl
LDH Lactic acid

31. MP : NOT SEEN
ICT (PV –ve)
(PF-ve)

32. Blood CULTURE
• Blood culture shows no growth.

33. ECG: SINUS TACHYCARDIA
Trops: <0.010
Pro BNP 284.3

34. Chest Xray
PA-view

35. ar infarcts noted in bilateral basal.
d involutional changes noted evident as prominent intra and ex
t frontal, temporal and right temporo-parietal lobes as detailed
ovascular ischemic changes seen involving subcortical andperiv
nbilateral matter.basal ganglia
ogistMIT/rang

36. EEG: Consitent with Encephalopathy.

37. DIAGNOSIS:

38. Neuroleptic malignant syndrome.
Secondary to drugs

39. Treatment and Hospital course:
• Initially the pt. was managed in ER:
• IV LINE WAS MAINTAINED.
• INJ CEFTRIAXONE NA 1g IV STAT
• NG TUBE AND FOLLEYS WERE PASSED.
• Ward management:
• (Suspected meningitis)
• Inj meropenem 1g IV 8hrly
• Inj vancomycin 1g IV 12 hrly
• Inj Bofalgan 1g IV SOS
• Pt. did not respond.
• Tab Bromocriptine 2.5 mg (2tab ) TDS N/G
• Tab Amantidine 100 mg OD N/G
• Tab Vinolin 2mg OD

40. • Pt . Became afebrile CPK Levels declined(166) and pt .was discharged
on home care.
• Take home medications:
• Tab Neolmin B.D