Abrupt chlordiazepoxide withdrawal as a risk factor for neuroleptic malignant syndrome with autonomic manifestation of ileus

Neuroleptic Malignant Syndrome (NMS) is an idiosyncratic and life-threatening side effect that typically occurs in response to dopamine receptor antagonist medications, such as typical and atypical antipsychotics, as well as metoclopramide. It can also result from the withdrawal of dopaminergic agents like levodopa and amantadine. Three previous case reports described the occurrence of NMS in patients with a history of benzodiazepine (BZD) withdrawal. This report describes a 67-year-old female patient who was hospitalized at another hospital with a complaint of dyspepsia for a gastrointestinal work up. She had a long history of self-medicating with chlordiazepoxide (15–25 mg/day) and propranolol (10 mg, 2–3 times daily) for approximately 40 years due to generalized anxiety disorder and obsessive- compulsive disorder. During a psychiatric consultation, chlordiazepoxide was discontinued, and she was prescribed buspirone, citalopram and olanzapine (5 mg at night). Subsequently, she developed fever and chills, confusion, and abdominal pain accompanied with nausea and vomiting followed by a high fever (40 °C), muscle rigidity, tremors, autonomic instability, altered level of consciousness, leukocytosis, elevated creatine phosphokinase (3925 U/L) and ileus. She was managed under the diagnosis of Neuroleptic malignant syndrome(NMS) in another hospital. Abrupt cessation of benzodiazepines (BZD) in patients with a history of long-term use may trigger catatonia, which in some cases— especially when treated with antipsychotics— can progress to NMS. Ileus, likely as an manifestation of autonomic dysfunction, may represent an under-recognized complication of this syndrome. This association remains hypothetical and requires confirmation in larger studies.