Neuroleptic Malignant Syndrome Unmasked: A Case of Extrapyramidal Syndrome With Tardive Dystonia Leading to a Life-Threatening Crisis.

We present a 57-year-old male with a history of depression and Cotard's syndrome, admitted to the psychiatric ward due to worsening psychotic symptoms. His antipsychotic regimen was intensified, including haloperidol, olanzapine, and promethazine. One month later, he developed a progressive akinetic-rigid syndrome, evolving into severe axial rigidity, autonomic instability, and hyperthermia. After 168 days of hospitalization, he was transferred to the emergency department in a stuporous state, with metabolic acidosis, rhabdomyolysis, acute kidney injury, and elevated creatine phosphokinase. A diagnosis of neuroleptic malignant syndrome (NMS) was established based on Levenson's criteria. Immediate cessation of neuroleptics, aggressive supportive care, and treatment with bromocriptine, dantrolene, and benzodiazepines led to clinical improvement. Despite partial recovery, the patient remained with persistent dystonia and functional impairment. This case emphasizes the importance of early recognition of NMS, especially in non-psychiatric settings, to prevent severe complications. Internists should be aware of extrapyramidal syndromes, particularly when evaluating patients on chronic antipsychotic therapy. A multidisciplinary approach, including neurologists, psychiatrists, and rehabilitation specialists, is crucial to optimizing patient outcomes and reducing long-term disability.