An 18 year old male presented with four years duration of bipolar affective disorder (BPAD). His illness started with manic symptoms characterized by decreased need for sleep and rest, over activity, over cheerfulness, over planning and over spending. In the initial two years of his illness, he had multiple episodes of mania, each lasting for three weeks, after which he would recover spontaneously. In between he had a few depressive episodes when he would complain of poor sleep and appetite, lethargy, sad mood, and finding no interest in any activity.
During the last one year of his illness, the patient sought treatment from various medical facilities but did not continue any long-term management. During his last episode of mania, the treating psychiatrist prescribed olanzapine 10 mg/day, aripiprazole 15 mg BD, and sertraline 100 mg/day. After one week, the patient reported tremors when aripiprazole was stopped and olanzapine was increased to 20 mg/day along with sertraline 100 mg/day. The patient reported increase in tremors after two days and in next week he developed rigidity in all the four limbs associated with mutism, at which time the patient stopped all medications and presented to us with altered consciousness and no responsiveness to questions or commands. He had high grade fever associated with sweating and fluctuation of blood pressure. Non-contrast CT of the brain showed early atrophic changes. He was catheterized and was put on IV fluids. Adequate hydration was maintained and vitals were monitored. The patient was diagnosed with neuroleptic malignant syndrome, and his serum CPK at 1622 IU/L along with the characteristic symptoms and signs confirmed the diagnosis. He was started with bromocriptine 7.5 mg/day in divided doses, which was later increased to 15 mg/day with tab lorazepam 4 mg/day. The patient improved only minimally, and levodopa 125 mg three times a day was added. Then patient showed marked improvement over the next two weeks. He started speaking, and accepted food orally. The rigidity also reduced markedly and he started walking. During routine chest x-ray, signs suggestive of active tuberculosis were seen which were later confirmed with CECT chest. The patient was referred to chest and tuberculosis hospital. At the time of discharge he was ambulatory, had adequate oral intake and serum CPK had reduced to 106 IU/L. He was discharged with an advice to continue levodopa 125 mg, three times a day, bromocriptine 5 mg/day and lorazepam 2 mg/day and was asked to follow up in the out-patient department after one week with a plan to start prophylaxis for BPAD during follow up.