The neuroleptic malignant syndrome (NMS) is a potentially fatal complication of antipsychotic therapy. A retrospective study of nine patients seen over six years at the University Hospital, Kuala Lumpur (UHKL), is described. The estimated annualised incidence was 1.2 per 1000 in-patients with psychosis. No ethnic difference was detected. Clinical features were similar to experiences elsewhere, with wide variability seen in the severity of illness. The neuroleptic drugs implicated were haloperidol, trifluoperazine, chlorpromazine, fluphenazine and clopenthixol. Treatment consisted of withdrawal of offending drugs and supportive measures. Specific therapy was given to five patients. There was one death. At follow-up no deterioration was detected. A different neuroleptic drug was successfully re-introduced in four patients. In view of the wide usage of major tranquillizers, a high degree of clinical awareness of this serious complication is necessary for early diagnosis to reduce morbidity and mortality.
13 patients with the amenorrhoea-galactorrhoea syndrome who conceived during treatment with bromocriptine were reported. Mean period of amenorrhoea was 3.0 years. In ten patients galactorrhoea was noted for a mean period of 4.2 years while in three it was discovered during examination. Seven patients presented with primary infertility. Menses returned in all cases after a mean duration of 2 months of treatment with bromocriptine at an average dose of 5. 86 mg daily. Mean serum prolactin was 4344 mUll (range 750 mU/l to 23,000 mU/l) before treatment and this declined to 186 mU/l with treatment. Seven patients became pregnant 5 to 25 months of treatment while six conceived after first menses. 21 pregnancies resulted from the thirteen patients. There was one spontaneous abortion and one premature delivery in which the baby died. Of the 16 live- births, there were twelve girls and four boys and their mean birth-weight was 2932 g. All were normal at birth and during subsequent developments except one with congenital dislocation of hip. It is concluded that bromocriptine is effective in restoring menstrual cycles and fertility by lowering serum prolactin in patients with the amenorrhoea-galactorrhoea syndrome. Bromocriptine may be safe for use during pregnancy, but it is suggested that the medication should be stopped immediately after conception unless tumour growth is apparent.
Macroprolactinoma has the potential to cause base of skull erosion and often extends into the sphenoid sinus. Rapid shrinkage of this invasive tumor following dopamine agonist therapy has been postulated to cause unplugging of the eroded area, leading to cerebrospinal fluid leakage. To the best of our knowledge, the occurrence of spontaneous cerebrospinal fluid leak in treatment-naive prolactinomas is very rare, the majority of which involve undiagnosed macroprolactinomas. We describe here a lady presented late with giant macroprolactinoma, complicated by cerebrospinal fluid leakage. This case raised the dilemma in the management pertaining to the role of either pharmacotherapy or surgical intervention, or combination of both. As she strictly refused surgery, she was treated with bromocriptine which was later changed to cabergoline. On follow-up, there was cessation of cerebrospinal fluid leak, marked reduction of serum prolactin level, and imaging evidence of tumor shrinkage. The majority of patients with medically induced cerebrospinal fluid leakage will require surgical procedures to overcome this complication; however, there are isolated cases of leakage resolution on continuing dopamine agonist therapy while awaiting surgery. The use of dopamine agonist does not necessarily cause worsening of cerebrospinal fluid leakage and instead may produce spontaneous resolution as in this case.