Our patient was a 71 year-old male admitted for acute respiratory failure secondary to aspiration pneumonia in the setting of advanced Parkinson’s disease (PD) requiring endotracheal intubation. After multiple failed attempts to extubate in light of supraglottic edema, the patient underwent a tracheostomy in the operating room (OR) with propofol, lidocaine, fentanyl and vecuronium anesthesia induction agents in addition to chronic levodopa and total parenteral nutrition (TPN) initiated preoperatively. However, 5 hours after the uneventful procedure the patient developed a refractory fever of 102.4 degrees Fahrenheit persisting for 7 days. Physical exam revealed sudden onset extreme muscle rigidity, nocturnal akinesia, disrupted sleep pattern and worsening physical distress absent prior. Subsequent work-up included chest radiography (CXR) which showed interval improvement of the patient’s aspiration pneumonia, negative growth on culture findings, CT Brain imaging showing no acute findings and an unremarkable urinalysis though the CK level was mildly elevated at 266 U/L. Upon 24 hours of lowering the protein content transfused in the patient’s TPN regimen however, his previously refractory fever resolved along with improvement of neurological deficits.
Discussion:
Neuroleptic malignant-like syndrome (NMLS) is a rare though life-threatening neurologic emergency with a mortality of 30% typically related to the sudden withdrawal or reduction of antiparkinsonian medications, most commonly dopamine (Wei & Chen, 2014). Other known precipitants have been documented in literature including acute infection, hypovolemia, cholinesterase inhibitor use, and rapid antiparkinsonian medication switches. TPN, to the best of our knowledge however, is a rare precipitating etiology as the nutritional protein element may compete with levodopa and subsequently limit its gastrointestinal absorption. One study suggested L-leucine and L-arginine amino acids competed with levodopa for transporter substrates across luminal enterocyte membranes (M, et al., 2014). Unlike neuroleptic malignant syndrome (NMS) which is an adverse reaction to neuroleptic use, our patient was not exposed to any such medications. Along with no previous adverse reactions to anesthetic agents, no withdrawal of his chronic dose consistent antiparkinsonian medications and ultimate improvement with TPN protein content reduction, it is important to keep such an etiological factor in mind when managing Parkinson’s patients presenting with symptoms of NMLS.
Conclusions:
One of the most common neurologic disorders affecting approximately 1% of those older than 60 years in age, PD follows a chronic debilitating course with well documented catastrophic complications. NMLS is a rare complication generally precipitated by the abrupt withdrawal or reduction of antiparkinsonian medications. TPN associated NMLS warrants further research to elucidate the mechanism of its occurrence and limit future morbidity and mortality.
References:
M, C., et al (2014). The molecular mechanism of intestinal levodopa absorption and its possible implications for the treatment of Parkinson’s disease. Journal of Pharmacology and Experimental Theraupeutics , 114-123.
Wei, L., & Chen, Y. (2014). Neuroleptic malignant-like syndrome with a slight elevation of creatine-kinase levels and respiratory failure in a patient with Parkinson’s disease. Patient Preference and Adherence , 271-273.