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Introduction: Neuroleptic malignant syndrome (NMS) is an emergent, often fatal, medical condition associated with the use of dopamine receptor antagonist medications. Fever, muscle rigidity, autonomic instability and altered mental status are known to be the hallmarks of the disease. In contrast with the typical presentation, Atypical NMS often presents with a different set of symptoms, making diagnosis difficult. It is important to use clinical acumen to make a timely and efficient diagnosis of NMS. We present a case of Atypical NMS in a 21 year old male. Clinical Case Pt is a 21 year old African American male with previous psychiatric history of schizophrenia, bipolar disorder, acute dystonia, and tardive dyskinesia. Pt was transferred from county jail to the emergency room with decreased activity, drooling, howling, and altered mental status. During this time patient was in isolation for previously erratic behavior. Per jail records this was an ongoing process for 2-3 days prior to transfer. Conversations with staff at jail state that pt was tachycardic and hypertensive at times during this episode yet when asked for full records they declined and explained they “don’t keep” charts or records. Jail nurses were also able to tell us his medications include haldol decanoate, oral haldol and artane yet had been refusing medications in recent days to weeks. They were unable to tell us anything about PRN medications given during this period of time. On admission to the hospital he was in pain, moderately stiff, bradykinetic, unable to phonate secondary to oral bradykinesia and minimally encephalopathic. Vital signs including temperature were unremarkable on admission and throughout hospitalization. Lab findings indicated elevated creatinine kinase of 18,963 IU/L. Due to components of the history and physical exam, laboratory and imaging studies, it was determined that this patient was presenting with atypical NMS and bromocriptine therapy was initiated. The patient steadily improved back to baseline over a 22 day admission, much of which was spent waiting for placement. Discussion: It is essential to recognize NMS to prevent associated mortality. Recognition of this disease process can often be difficult as presentations may vary. There is established literature on atypical presentations of NMS; presentations without hallmark signs and symptoms such as fever, muscle rigidity, autonomic instability and altered mental status. It is the goal of this case to discuss NMS pathogenesis, variations in presentation of NMS, the differential diagnosis, and associated treatment.



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