title: Fever, confusion, acute kidney injury: is this atypical neuroleptic malignant syndrome following polypharmacy with clozapine and risperidone?
abstract: OBJECTIVE
  Clozapine is the gold-standard antipsychotic medication for treatment-refractory schizophrenia (TRS). However, one potentially lethal side effect of clozapine, as with other antipsychotics, is neuroleptic malignant syndrome (NMS) which could present differently in clozapine therapy. 'Atypical NMS' is a recognised variant of NMS with less rigidity and delayed elevation of creatine kinase; this variant is associated with clozapine.
  
  
  METHODS
  A case from the author's clinical practice was reviewed.
  
  
  RESULTS
  A 67-year-old man with TRS was treated with clozapine. Unfortunately, his physical condition deteriorated and he presented with atypical NMS, which initially was treated as presumable urinary tract infection.
  
  
  CONCLUSIONS
  Atypical NMS is associated with clozapine. This case exposes the potential difficulties in diagnosis, and highlights the importance of considering less common diagnoses in acutely unwell psychiatric patients.
authors.affiliation: Consultant Psychiatrist, Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia.
authors.forename: Scott
authors.initials: S
authors.lastname: Cherry
authors.affiliation: Clinical Academic Psychiatrist, Metro South Addiction and Mental Health Services, Brisbane, QLD, and; Associate Professor, University of Queensland School of Medicine, Woolloongabba, QLD, Australia.
authors.forename: Dan
authors.initials: D
authors.lastname: Siskind
authors.affiliation: Psychiatry Registrar, Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia valeria.spivak@health.qld.gov.au.
authors.forename: Valeria
authors.initials: V
authors.lastname: Spivak
authors.affiliation: Psychiatry Registrar, Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia.
authors.forename: Daniel
authors.initials: D
authors.lastname: Wysoczanski
authors.affiliation: Psychiatry Registrar, Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia.
authors.forename: Priyangika
authors.initials: P
authors.lastname: Halangoda
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced; D000368:Aged; D014150:Antipsychotic Agents / Q000009:adverse effects*; D003024:Clozapine / Q000009:adverse effects*; D003221:Confusion / Q000139:chemically induced; D005334:Fever / Q000139:chemically induced; D006801:Humans; D008297:Male; D009459:Neuroleptic Malignant Syndrome / Q000209:etiology*; D019338:Polypharmacy; D018967:Risperidone / Q000009:adverse effects*; D012559:Schizophrenia / Q000188:drug therapy*
chemical_list: D014150:Antipsychotic Agents; D003024:Clozapine; D018967:Risperidone
keywords: atypical; clozapine; neuroleptic malignant syndrome