PHS

 Q: 73 years old male with a known history of Parkinson's Disease is admitted to ICU with high fever and symptoms like "Neuroleptic Malignant Syndrome" (NMS). Patient's levodopa should be? (select one)

A) completely stopped

B) started at previous dose

C) cut into half

D) escalate the dose

Answer: B

Patient has probably developed parkinsonism-hyperpyrexia syndrome (PHS) which is very much like NMS. This mostly occurs during the dose adjustment phase of levodopa. These patients simultaneously require management on two aspects, readjusting the levodopa dose and controlling the severe symptoms. Levodopa (or if any other Dopamine Agonist is used), the dose should be brought back prior to adjustment. These patients usually can't swallow. Naso-Gastric tube (NGT) should be inserted as the first line of treatment and levodopa should be given - again with the dose prior to the adjustment - as soon as possible. 

If NGT can not be inserted, apomorphine should be given intravenously. Apomorphine can be given as scheduled doses or in continuous infusion. If neither NGT can be inserted or IV can be obtained, rotigotine can be given transdermally. 

PHS symptoms are treated as NMS with dantrolene, bromocriptine, and/or amantadine.

#neurology

References:

1. Newman EJ, Grosset DG, Kennedy PG. The parkinsonism-hyperpyrexia syndrome. Neurocrit Care 2009; 10:136. 

2. Factor SA. Fatal Parkinsonism-hyperpyrexia syndrome in a Parkinson's disease patient while actively treated with deep brain stimulation. Mov Disord 2007; 22:148.