Table 1.

Symptoms of NMS and treatment

1.Symptoms of NMS	sudden agitation, delusional beliefs; consciousness disturbances; fever over 39 °C.; ‘cogwheel ‘muscle rigidity; tremor and sopor; vital signs as follows; blood pressure 80/50 mmHg and heart rate 100 beats/minute.
2. Laboratory results	CRP 334,90 mg/dl, LDH 357 U/l, CPK 6988 U/I, GFR 20 ml/min, creatinine 2.55 mg/dl.
3. NMS treatment	a. All antipsychotic drugs (aripiprazole and quetiapine) and lamotrigine were withdrawn. b. Amantadine (up to 200 mg/d), lorazepam (3 mg/d) and bromocriptine (3.75 mg/d) were initiated. c. The patient’s condition improved after 5 days of the treatment.
4.Further treatment of the patient	a. Because of severe psychotic symptoms clozapine and lamotrigine were commenced very slowly. Clozapine has a low risk of causing NMS and was titrated from 12.5 mg/per week to a dose of 200 mg/d, whereas lamotrigine was titrated from 25 mg/d every two weeks to a dose of 225 mg/d. b. After 4 months of treatment, clinical improvement was observed and the patient was discharged from hospital in a good general condition.

CPK creatine phosphokinase, CRP C reactive protein, GFR glomerular filtration rate, LDH lactate dehydrogenase, NMS neuroleptic malignant syndrome