Reversible abnormality of the splenium in a bipolar patient with neuroleptic malignant syndrome

To report reversible abnormality of the splenium in a bipolar patient with neuroleptic malignant syndrome (NMS).

We studied a 23-year-old male who received oral and parenteral neuroleptics, atypical antipsychotic agents, and mood stabilizers, as well as a course of six electroconvulsive therapy treatments, for an episode of mania. He improved. Five days after discharge on maintenance atypical antipsychotic agents and mood stabilizers, he returned with symptoms suggestive of NMS. Laboratory investigations revealed leucopenia, thrombocytopenia, and elevated creatine phosphokinase levels. Brain magnetic resonance imaging showed swelling of the splenium with centrally restricted diffusion; there was no other abnormality. He was defensively treated with antimicrobials, methylprednisolone, and bromocriptine.

Clinical recovery was complete after nine days, and the splenium lesion resolved after four further days; there were no neuropsychiatric sequelae. Nine months later, the patient remains well on maintenance lithium therapy.

This is the first report of an isolated splenial lesion reversing within days of resolution of NMS. The outcome supports the recent literature which suggests that an isolated splenial lesion does not need investigation, and that prognosis depends on the underlying disorder, and not on the presence or absence of the splenial lesion.