Concurrent Duloxetine Withdrawal and Neuroleptic Malignant Syndrome Mimicking Creutzfeldt-Jakob Disease: A Case Report (P2.219)

Objective: To describe a case of iatrogenically induced CJD symptoms.

Background: The constellation of rapidly progressive dementia, myoclonus, rigidity, and hallucinations suggests a diagnosis of Creutzfeldt-Jakob Disease (CJD), particularly the Heidenhain variant. We present a patient with the clinical picture of CJD. Upon further investigation, this represented an unusual combination of duloxetine withdrawal preceding neuroleptic malignant syndrome (NMS).

Design/Methods: Case report.

Results: A 61 year old man developed severe vomiting two days after abruptly discontinuing pregabalin. He was unable to tolerate his medications, including duloxetine. The patient presented the next day with auditory and visual hallucinations, dizziness, tremor, diaphoresis, leg cramping, and unsteadiness. The following day, the hallucinations worsened, and he developed micropsia. Head CT was normal. Overnight the patient received haloperidol, lorazepam, quetiapine, and olanzapine for agitation. By morning he was increasingly distracted and preoccupied with visual hallucinations. He developed marked rigidity, myoclonic jerks, and startle myoclonus. He was then sent for a brain MRI. Prior to the MRI, he received an additional dose of olanzapine for sedation. He became agitated, diaphoretic, febrile, and increasingly rigid. He was emergently treated for NMS and sedated with benzodiazepines. No images were able to be obtained. The patient stabilized and continued to improve off of duloxetine and neuroleptics. He returned to baseline and was discharged home.

Conclusions: We describe a highly-functioning man with a rapidly progressive cognitive impairment, visual hallucinations, rigidity, and startle myoclonus. Although this picture is concerning for CJD, after treatment for NMS and continued withholding of duloxetine, his symptoms resolved. Sudden duloxetine withdrawal may cause agitation, psychosis, hallucinations, and confusion; however, this patient’s presentation was particularly severe and compounded by neuroleptic malignant syndrome. Physicians should therefore consider iatrogenic causes in suspected CJD.

Disclosure: Dr. Zucker has nothing to disclose. Dr. Miller has nothing to disclose. Dr. Rubin has nothing to disclose. Dr. Wright has nothing to disclose. Dr. Schloss has nothing to disclose.