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A Tale of Three Hot Cases: - Management of the Acute Dysautonomias on Intensive Care


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•Serotonin syndrome and neuroleptic malignant syndrome (NMS) are two acute dysautonomias that often prove difficult to differentiate (1,2)
•Multi-pharmacy can often prevent isolation of a single causative agent (1,2)
•Three patients presented over five weeks to our intensive care with acute dysautonomic symptoms

Case 1

•32 yo male, known schizophrenia
•Confused, febrile, high glucose
•DHx: trihexyphendyl, aripiprazole, lithium, clozapine
•Altered mental status, severe rigidity, temp 40.1
•Invx: pH 7.24, lact 3.4 Glucose >90, AKI, CK 5663. CT and lumbar puncture NAD

Case 2

•51yo, depression
•Reduced GCS , confusion, agitation
•DHx: venlafaxine, escitalopram, olanzapine
•Increased tone, rigidity, clonus, temp 38.1
•Invx: NAD

Case 3

•28 yo, bipolar disorder
•Reduced GCS, confusion, clonus, diaphoresis
•DHx: multiple antipsychotics


Case 1

•Rapidly deteriorated, developing severe hyperpyrexia (>43℃)
•Required multi-organ support
•Despite active cooling, cardiac arrest occurred within 24 hours

Case 2

•Required early intubation and a prolonged wean. Ongoing neurological sequelae

Case 3

•Intubated early. Symptoms improved rapidly with supportive treatment


•In all cases, acute dysautonomia was a diagnosis of exclusion. It remains essential to investigate for life-threatening differentials in suspected cases
•The picture was consistent with NMS, SS or possible overlap syndrome in each case
•It is uncertain whether differentiation is essential acutely, with most guidance on initial management strongly stressing best supportive care (3,4)
•It is important to be aware that common ITU drugs can precipitate or worsen the acute dysautonomias e.g. metoclopramide and fentanyl in serotonin syndrome
•Specific medical management may be helpful in the case of a clear differential, otherwise such treatments may in fact be detrimental (3,4)
•Early identification and consideration of acute dysautonomias as part of our differential diagnosis, alongside best supportive management may improve clinical outcomes for such patients (1,4)


Dosi R, Ambaliya A, Joshi H, Patell R. Serotonin syndrome versus neuroleptic malignant syndrome: a challenging clinical quandary. BMJ case reports. 2014 Jun 23;2014:bcr2014204154

Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014 Feb 19;348:g1626

Boyer E. Serotonin Syndrome. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed 27/6/17)

Wijdicks E. Neuroleptic Malignant Syndrome. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed 27/6/17)

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