Fever: the first symptom of a unique excited delirium syndrome in a psychotic patient – a case report

Cilj: Osvijestiti mogućnost postojanja ekscitirajućeg delirantnog sindroma u psihotičnog pacijenta s povišenom tjelesnom temperaturom. Prikaz slučaja: Pacijent u dobi od 32 godine prisilno je hospitaliziran pet puta u posljednjih 11 godina na Klinici za psihijatriju KBC-a Rijeka. Unazad 14 godina u psihijatrijskom je tretmanu pod dijagnozom paranoidne shizofrenije, a ekscitirajući delirantni sindrom javio se tri godine od početka liječenja. U posljednje dvije prisilne hospitalizacije prezentirao se uz kliničku sliku psihotičnosti i poremećene svijesti (po opisu delirantnu), psihomotorne agitiranosti, nesuradljivosti, uz simptome autonomne hiperreaktivnosti (tahikardija, tahipneja, znojenje, povišenje krvnog tlaka) te zakočene muskulature. Osim toga, pacijent ima stalnu potrebu za razodijevanjem i izraženu privučenost ogledalima. Trećeg dana posljednje hospitalizacije razvila se povišena tjelesna temperatura koja se poklapa s primjenom veće doze antipsihotika. Najprije je postavljena sumnja na maligni neuroleptični sindrom i ukinuta je antipsihotična terapija, ali bez značajnijeg učinka na psihičko i tjelesno stanje. Dijagnostička obrada nije pokazala značajno povišenje razine kreatin fosfokinaza niti nalaz mioglobina u urinu. S obzirom na to, ponovno su primijenjeni antipsihotici u liječenju te postupno dolazi do poboljšanja i psihičkog i tjelesnog stanja bolesnika te se tada počinje sumnjati da se radi o jedinstvenom ekscitiranom delirantnom sindromu. Zaključak: Pojava vrućice u psihijatrijskih bolesnika dijagnostički je i terapijski izazovna. Rano razmatranje sindroma hipertermije povezanih s liječenjem od vitalne je važnosti. Dijagnostička dvojba između malignog neuroleptičkog sindroma i ekscitirajućeg delirantnog sindroma značajna je jer su uključeni različiti terapijski pristupi, a radi se o dvama potencijalno letalnim sindromima.Aim: To raise awareness about the existence of excitated delirium syndrome in a psychotic patient with fever. Case report: A 32-year-old patient was forcibly hospitalized five times in the last 11 years at the Clinic for Psychiatry at the University Hospital Center Rijeka. For the past 14 years, he has undergone sychiatric treatment with the diagnosis of paranoid schizophrenia, and the excitatory delirium syndrome occurred three years after the beginning of the treatment. In the last two involuntary hospitalizations, the patient was presented with a clinical picture of psychosis and impaired consciousness (delirious by description), psychomotor agitation, non-cooperation with symptoms of autonomic hyperreactivity (tachycardia, tachypnea, sweating, increased blood pressure) muscle rigidity. In addition, the patient had a constant need for undressing and a pronounced attraction to mirrors. On the third day of the last hospitalization, there was elevated body temperature which coincided with the administration of a higher dose of antipsychotics. Malignant neuroleptic syndrome was first suspected and antipsychotic therapy was discontinued, but without a significant effect on mental and physical condition. Diagnostic processing did not show a significant increase in creatine phosphokinase levels or the finding of myoglobin in the urine. Taking this into account, antipsychotics were reintroduced in the treatment, and the mental and physical condition of the patient gradually improved, and then a unique excited delirium syndrome was suspected. Conclusion: The occurrence of fever in psychiatric patients is diagnostically and therapeutically challenging. Early consideration of treatment-related hyperthermia syndromes is vital. The diagnostic dilemma between malignant neuroleptic syndrome and excitatory delirium syndrome is significant because different therapeutic approaches are involved, and these are two potentially lethal syndromes