Parkinsonism-Hyperpyrexia Syndrome in a patient undergoing upper gastrointestinal surgery: A case report

Abstract

Background: Parkinsonism-hyperpyrexia syndrome (PHS) is a potentially life-threatening condition that occurs due to the abrupt withdrawal or significant dose reduction of antiparkinsonian medications. It presents similarly to neuroleptic malignant syndrome (NMS) and is characterized by severe rigidity, fever, autonomic instability, and altered mental status.

Case: A 62-year-old male with a 10-year history of Parkinson's disease (PD) underwent laparoscopic mesh repair for a left-sided diaphragmatic and large hiatus hernia. His antiparkinsonian medications included levodopa/carbidopa, amantadine, pramipexole, and benzhexol. Medications were withheld as part of the nil per os (NPO) status. Postoperatively, he developed withdrawal features, including tremors, difficulty speaking, tachycardia, hypertension, fever, and sweating. PHS, resulting from the withdrawal of antiparkinsonian medications, was diagnosed. The patient was transferred to the intensive care unit (ICU), intubated, and his antiparkinsonian medications were reintroduced. The patient's condition improved gradually, and he was discharged home on the 15th postoperative day.

Discussion: The abrupt discontinuation of antiparkinsonian medications precipitated PHS in our patient. Recognizing the clinical picture of PHS and differentiating it from other possible conditions, such as neuroleptic malignant syndrome and malignant hyperthermia, is pivotal. Management involves resuming medications and providing supportive care. Early recognition and prompt reintroduction of the antiparkinsonian medications are essential for the patient's recovery.

Conclusion: PHS is a rare but potentially life-threatening condition that occurs due to the withdrawal of antiparkinsonian medications, leading to an acute hypodopaminergic state. Our case emphasizes the importance of careful perioperative management of antiparkinsonian medications and early recognition and management of withdrawal symptoms in patients with Parkinson's disease undergoing surgery.

Keywords: Parkinson’s disease; antiparkinsonian medications; neuroleptic malignant syndrome; parkinsonism-hyperpyrexia syndrome.; perioperative management.

Figure 1.

Hemodynamic changes throughout the perioperative course, where the x-axis represents the perioperative events, and the y-axis represents the hemodynamic values. Zero hour is the time the last dose of levodopa was received preoperatively. Subsequent time points are the number of hours elapsed since the last dose of levodopa. (SBP: Systolic blood pressure, DBP: Diastolic blood pressure, HR: heart rate, bpm: beats per minute).