A Diagnostic Dilemma—Severe Hyperthermia and Rigidity in a Young Man with Polysubstance Use: A Case Report

TL;DR

A young man with drug use and severe hyperthermia presented a complex case of possible neuroleptic malignant syndrome, highlighting diagnostic challenges and treatment strategies.

Contribution

This case report emphasizes the diagnostic difficulties and management of NMS in patients with limited medical history and polysubstance use.

Findings

The patient's symptoms were managed with dantrolene, leading to rapid improvement in rigidity and hyperthermia.

Urine toxicology confirmed amphetamine and cocaine use, complicating the differential diagnosis.

The case highlights the importance of considering NMS in patients with psychiatric histories and substance use disorders.

Abstract

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening condition often associated with dopamine antagonist use. However, its overlap with other hyperthermic and toxidromic syndromes presents significant diagnostic challenges. We present the case of a 27-year-old man with severe hyperthermia, altered mental status, and diffuse rigidity, ultimately managed as possible NMS but with multiple differential diagnoses.

We describe a diagnostically challenging case of a 27-year-old male with an unknown medical history presenting with altered mental status, absence of personal identification, severe hyperthermia, and positive systemic inflammatory response syndrome criteria. The patient initially presented with hyperthermia (42.1 °C), tachycardia, tachypnea, diaphoresis, agitation, and rigidity. Initial lab findings demonstrated leukocytosis, elevated creatine kinase, metabolic acidosis, and rhabdomyolysis. Computed tomography ruled out acute anatomical abnormalities, while urine toxicology returned positive for amphetamines and cocaine. The patient required sedation, rapid sequence intubation, and dantrolene administration, which rapidly resolved his rigidity and hyperthermia and stabilized his vital signs. He was admitted to the intensive care unit, where supportive care, including antipyretics, hydration, and muscle relaxants led to gradual improvement. When the patient became less altered, he admitted to a history of aripiprazole use for schizophrenia, as well as daily amphetamine and cocaine use.

This case underscores the importance of considering neuroleptic malignant syndrome in patients with atypical presentations, suspicion for comorbid psychiatric conditions, and substance use disorder. Timely diagnosis, discontinuation of the offending agent, and targeted therapies such as dantrolene are critical in preventing complications. We highlight the diagnostic challenges and management strategies for NMS in the context of a limited history and severe hyperthermia.