Forced Diuresis and Expedient Blood Pressure Control in the Management of Quetiapine Induced Neuroleptic Malignant...

This case report intends to highlight the importance of safeguarding renal function from rhabdomyolysis in neuroleptic malignant syndrome (NMS) by concomitant administration of parenteral fluids at a high rate together with high doses of parenteral loop diuretics (we utilised 6 mg bumetanide daily) and tailed over a few days, in order to preserve glomerular/renal medullary perfusion and nephron function.

This case describes an elderly lady previously diagnosed with Lewy body dementia who had been started on low dose quetiapine a few days previously and presented with an acute 24 - 48 hour onset of fever, generalised stiffness, rapidly becoming uncommunicable and with high blood pressure. Haemoglobinuria was present prompting intravenous treatment with labetalol to address the BP, whereas rapid isotonic saline fluid infusions together with intravenous high dose bumetanide were instituted to safeguard the kidneys against damage due to nephron deposition, both from haemoglobinuria as well as possibly myoglobin from rhabdomyolysis. A working diagnosis of the neuroleptic malignant syndrome with secondary malignant hypertension was made, and the quetiapine withdrawn. Blood pressure was after that subsequently controlled on amlodipine, and the haemoglobinuria quickly settled within 24 hours, with large amounts of dilute urine being passed on account of the forced diuresis. The fact that renal function and creatinine kinase remained normal is testimony to how these expedient measures averted progression to both rhabdomyolysis and renal failure in this case, thereby ameliorating prognosis.

The patient was kept on infused fluids with maintenance bumetanide alone, achieving a full clinical recovery within the following 3 days.