Today we went through a case of fever which may have been due to infection, malignancy or drug fever.
We went through causes of drug fever such as hypersensitivity (this can be seen with almost any drug, but commonly seen with antimicrobials and antipsychotics)
Important adverse drug reaction that have fever are Malignant hypertension, NMS and Serotonin syndrome.
NMS: is a syndrome of 1) altered mental status, 2) fever 3) marked rigidity (with associated CK elevation) 4) autonomic instability: hypertension, tachycardia
It is often seen with antipsychotic medication (usually "typicals", but can be atypical as well) OR withdrawal of
dopaminergic medications (e.g. antiparkinsonians)
Treatment is mainly discontinuation
of drug (or restarting if withdrawal), and support ( there may possibly be a role for dantrolene or bromocriptine)
Serotonin sydrome: is a distinct
disorder that results from overstimulation of serotonin receptors. (see linked article for various mechanisms)
Birmes P et
al. CMAJ 2003;168:1439-1442
Presentation can include
mental status change, CNS signs (hyperreflexia, myoclonus, rigidity), autonomic instability (including fever)
Treatment: Stop serotonergic
substance. If severe may need to be cooled or cyproheptadine (antihistamine
with antiserotonin effect)
How to differentiate: NMS vs. serotonin syndrome
Serotonin syndrome may have
shivering, hyperreflexia, myoclonus, flushing (all uncommon in NMS)
HERE is a great NMS review.
Here is a great Serotonin syndrome review
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