Abstract
We respond to the number of criticisms that Dr Gillman has raised about the case report, ‘An unrecognised case of withdrawal neuroleptic malignant syndrome’. 1
One area of criticism concerns the literature that we referred to. We are not able to comment on his perspective as ‘one of the only researchers (sic) who has published reviews of both NMS and ST’ (Neuroleptic Malignant Syndrome and Serotonergic Syndrome), but we note that the review he quotes with respect to this remark is still ‘in press’. It was not available to us when we drafted the case report.
We would also like to point out that what was published is a brief case report, not an exhaustive review of the current state of knowledge in respect of NMS. In our case report we acknowledged the paradoxical situation of a patient developing NMS on withdrawal of medication, a phenomenon that appears to be rarely reported. It is inevitable, therefore, that the previous reports that we refer to are sparse, to some extent selective and mostly not very recent.
Dr Gillman rightly points out that the cause–effect relationship between antipsychotics and NMS is still uncertain, and so is its status as a unitary and homogeneous entity – it remains a poorly understood condition. We do not agree that the literature in this field has ‘advanced usefully’ with respect to withdrawal NMS – we cannot find persuasive evidence in the literature by which the possibility of this diagnostic entity is categorically refuted. Indeed, two recent UK texts refer to the development of NMS against the background of medication withdrawal. 2,3
Dr Gillman further criticizes the actual clinical description we offered. All three authors were involved in a retrospective investigation of the case after the event of death had happened. The only information that was available, therefore, was that recorded in the case record. The retrospective diagnosis of NMS in this case was not based on the patient ‘suddenly collapsing’ – Dr Gillman acknowledges that the syndrome is poorly delineated, but our patient did show all symptoms and signs that are invariably formulated to be part of NMS. With respect to Dr Gillman's assertion that the report of the patient ‘suddenly collapsing’ is ‘almost certainly factually incorrect’, then we refer back to the information that is present in the case record. The record describes the patient having been discovered lying on the floor, partially conscious and ‘clammy’ to the touch. In our view, this description is entirely consistent with the meaning of collapse as is found in any standard dictionary, i.e. to break down physically or mentally or to be in a state of prostration.
We are aware that creatine kinase (CK) can be raised in certain circumstances – it is highly unlikely that the patient in question had been exercising to any degree during the period of hospital admission in question. Dr Gillman further highlights that normal individuals may have high CK levels four days after moderate exercise. We are unaware that such individuals then go on to develop acute renal failure and subsequent intracerebral bleeds. Dr Gillman then illustrates his point with three reports of rhabdomyolysis, one of which deals with exertional heat illness and exertional rhabdomyolysis and is therefore not pertinent to our case. The second one deals exclusively with olanzapine-induced rhabdomyolysis – the authors refrained from generalizing their findings to ‘antipsychotics’. Needless to say our patient was not on olanzapine. The third pertains to a critical review of myopathies, caused by a variety of substances, particularly statins, but also red yeast rice and certain edible mushrooms. This review appears to have been carried out to tighten up on the diagnosis of toxic myopathies, ‘based on the consideration of currently known pathophysiologic mechanisms’. Again, it is not clear to us what the relevance of this review is to our case.
Having carefully considered Dr Gillman's criticisms, we remain of the view that in relation to the case that we reported the diagnostic criteria for NMS were met.
Finally, we are pleased that the case report has attracted interest. The fundamental motive behind the publication of the report was to raise awareness of the phenomenon of sudden death within an inpatient mental health setting, and the need to ensure that such deaths are thoroughly investigated both in the clinical sense and medico‐legally. We thank Dr Gillman, therefore, for the interest that he has shown.