Neuroleptic malignant syndrome (NMS) is a rare but life threatening condition associated with the use of antipsychotics and drugs that influence dopaminergic transmission. Although, typically it has been associated with classical antipsychotics, it can also be induced by atypical antipsychotics. It is unexpected situation of clozapine related NMS because of its rare extrapyramidal side effects. Its clinical presentation may include fever, muscular rigidity, alterede state of consciousness and autonomic instability. Catatonia is also a lethal condition characterized by posturing, agitation, waxy flexibility, mutism, echolalia and echopraxia. A substantial overlap exists between catatonic phenomena and features of neuroleptic malignant syndrome. In this case report we present a patient with clozapine induced NMS which evolved into catatonia.

A 52-year-old male was diagnosed psychotic depression six years ago and fluoksetin and olanzapine were given. In the following years, he was poorly responsive to his treatment and it was changed to risperidon and paroksetin. Because the clinical course did not improve; his drugs were replaced with clozapine two years ago. On his follow-up clozapine was administered rapidly increasing dosage. The patient admitted to our hospital with muscle rigidity, fever, leucocytosis, high creatine phosphokinase levels and NMS was diagnosed. He was put on bromocriptine. NMS resolved but catatonia developed. 10 sessions ECT were administered. Quetiapine was given after ECT for the antipsychiatric therapy. He has not had any NMS signs until now.

NMS is usually induced by the agents with dopaminergic affinity. It should always be kept in mind that all atypical antipsychotics including clozapine may induce NMS although not common. Our patient demonstrated clear features of NMS resolved into catatonia. This adds weight the theory that catatonia and NMS are closely related; possibly represent the same underlying pathology.

Keywords: catatonia, clozapine, neuroleptic malignant syndrome