Diagnostic, Treatment, and System Challenges in theManagement of Recurrent Neuroleptic Malignant Syndrome ona General Medical Service

Neuroleptic malignant syndrome (NMS), an iatrogenic form of malignant catatonia, carries high morbidity and mortality ratesespecially in the context of delayed recognition and standard intervention protocol of lorazepam trial. However, there is limitedguidance available through literature for further management if benzodiazepine treatment is ineffective and electroconvulsivetherapy (ECT) is not readily accessible. This case report describes a multimodal approach to address the diagnostic, treatment, andlogisticalsystemchallengesinanacutemedicalhospitalthroughthecaseofa69-year-oldmanwithschizophreniawhorepresentedfrom a psychiatric ward with neuroleptic malignant syndrome. We educated our inpatient colleagues for timely recognition ofhyperexcited subtype of catatonia to avoid iatrogenic progression to neuroleptic malignant syndrome and our medical colleagueson the clinical course of catatonic symptoms to avoid any further disagreements and delays in treatment. We advocated for timelyelectroconvulsive therapy in the setting of limited access and utilized creative pharmacologic strategies such as N-methyl-D-aspartate (NMDA) receptor antagonists and longer acting benzodiazepines while managing medical complications.