Neuroleptic malignant syndrome and early autonomic dysfunction

In their review article on neuroleptic malignant syndrome, Shalev & Munitz (Acta Psychiatr Scand 1986: 73:337-347), while commenting on atypical forms of NMS, state that Guze & Baxter (1) suggest that signs of autonomic dysfunction appear before other symptoms. However, in their own review, Guze & Baxter (1) have cited this statement from an editorial in Lancet which appeared in 1984 (2). Going through the same Lancet editorial on neuroleptic malignant syndrome, we find that the observation has been made based on a single case report of an atypical case of neuroleptic malignant syndrome, (3). The editorial states ‘‘signs of autonomic dysfunction such as tachycardia, labile arterial pressure, and sweating may precede the onset of the hyperthermia, acting as early warning signs”. Neither the Lancet editorial nor Guze & Baxter (1, 2) have explicitly stated that signs of autonomic dysfunction are seen regularly in the early phase of NMS before appearance of a full-blown syndrome an assertion which Shalev & Munitz have erroneously attributed to Guze & Baxter (1).