Neuroleptic malignant syndrome — structured clinical viva

Reject more IM olanzapine. This is likely evolving NMS after multiple dopamine antagonists. Further antipsychotic is a fail.^[1]

Diagnosis. Map to Gurrera IEC: recent dopamine antagonists; fever; rigidity; altered MS; CK ≥4× ULN; autonomic features. Pursue infection/metabolic exclusion concurrently.^[1]

Differentials. Serotonin toxicity (need serotonergic drugs + clonus/hyperreflexia — Hunter framework); malignant catatonia (overlap; benzos/ECT); heat stroke; CNS infection; MH if perioperative. Examine reflexes carefully.^[2][5]

Immediate care. Stop all DA antagonists; ABCDE; cool; IV fluids; monitored bed/ICU if unstable; serial CK/renal function; benzos for agitation; watch respiratory failure and AKI (mortality drivers).^[6]

Specific Rx honesty. No RCTs. Support first. Bromocriptine/dantrolene/ECT considered for severe/non-resolving disease; Kuhlwilm severe-subgroup signal; BAP supports ECT in catatonic spectrum/NMS interface.^[3][5]

Rechallenge. Only after full recovery + delay (often ≥~2 weeks); different agent; slow titration; monitoring. Rosebush: most can eventually tolerate; timing matters.^[4]