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Atypical neuroleptic malignant syndrome and non-alcoholic Wernicke’s encephalopathy
  1. Esther Shan Lin Hor1,
  2. Gurpreet Pal Singh1,
  3. Nurul Akhmar Omar2 and
  4. Vincent Russell3
  1. 1Internal Medicine, Taiping Hospital, Taiping, Malaysia
  2. 2Radiology, Taiping Hospital, Taiping, Malaysia
  3. 3Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
  1. Correspondence to Dr Esther Shan Lin Hor; ehslin{at}


We report the case of a middle-aged woman with a history of bipolar disorder, in the absence of alcohol or substance misuse. The patient had been maintained on fluphenazine decanoate depot and now presented acutely with cognitive dysfunction and rigidity. Laboratory tests revealed elevated creatine kinase, acute kidney injury with metabolic acidosis and transaminitis, leading to a provisional diagnosis of neuroleptic malignant syndrome (NMS). Neuroleptics were withheld; dialysis was commenced; and blood biochemistry parameters improved in tandem. However, mental status changes persisted, and re-evaluation revealed multidirectional nystagmus with bilateral past-pointing. MRI confirmed the diagnosis of Wernicke’s encephalopathy (WE). Prompt recovery followed treatment with high-dose intravenous thiamine. We discuss the co-occurrence of NMS and non-alcoholic WE—highlighting the need for a high index of suspicion for these relatively rare neuropsychiatric diagnoses which are often missed in those with atypical presentations.

  • drugs: psychiatry
  • neurology

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  • Contributors ESLH and GPS were involved in patient care and in the initial drafting of the manuscript. GPS was the attending ward physician and NAO was the radiologist involved in the patient’s imaging and diagnosis. VR supervised revision and editing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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