Initial bloods showed a raised white cell count (WCC) of 13.5 × 109/l (neutrophils 8.26 × 109/l) but a C-reactive protein (CRP) < 1 mg/l. Gamma-glutamyl transpeptidase (GGT) was 1091 U/l. A urine drug screen confirmed the presence of opioids only. On the post take ward round

later that day he was observed to be sweating profusely, agitated and tachycardic. He remained confused and spoke of concerns regarding gangs with knives. Nystagmus and sluggish pupils were noted. Both venlafaxine and quetiapine were held. He was reviewed by neurology on day 2 and choreiform movements noted in his legs, arms and head. Further Inhibitors,research,lifescience,medical lorazepam was required for agitation. Creatine kinase (CK) was 13,928 U/l and a working diagnosis of Selleckchem GSK-3 inhibitor neuroleptic malignant syndrome was established. A planned lumbar puncture was deferred and management was focused on ensuring adequate hydration and management of agitation with further doses of benzodiazepines as required. Repeat liver function tests (LFTs) showed elevated aspartate transaminase (AST; 290 U/l) and alanine transaminase (ALT; 105 U/l) with a small decline in GGT to 900 U/L. Inhibitors,research,lifescience,medical Systolic blood Inhibitors,research,lifescience,medical pressure fell to lie between 80 and 100 mmHg and he was intermittently tachycardic to a maximum of 120 bpm. The patient was verbally aggressive toward staff and removed several IV cannulae. He was placed on one-to-one nursing observations. Urea and electrolytes were normal on day 3 and CK had fallen to 11,461 U/l. A repeat

CK later that day showed a further fall to 5877 U/l. He underwent a lumbar puncture under sedation. He remained disruptive and agitated and was moved

to a side Inhibitors,research,lifescience,medical room. On day 4 he appeared less agitated. CK was 2708 U/l with normal urea and electrolytes, CRP and WCC. Cerebrospinal fluid (CSF) analysis was normal. On day 5 he was confused and wandering, eventually absconding from the ward. He was returned by the police and was aggressive on his return. He was referred to and assessed by the Inhibitors,research,lifescience,medical liaison psychiatry team. On assessment he remained disorientated, believing that he was in prison. Mood appeared labile and speech was largely incoherent. He remained concerned for his safety and believed that he was in danger of being stabbed. Choreoathetoid movements were again noted. He was distracted at interview and appeared to be responding to stimuli. The medical team was advised to continue to hold his psychotropic medications and to use benzodiazepines however as required for the management of agitated behaviour while his medical investigations continued. A collateral history from his community addictions team key worker revealed that he had been stable on methadone for several years and that there were no concerns of recent substance misuse. On day 6 he threw a rubbish bin toward another patient. He was no longer tachycardic. WCC was 7.4 × 109/L, alkaline phosphatase (ALP) 61 U/l, AST 59 U/l, ALT 65 U/l and GGT 657 U/l. He underwent an MRI brain scan under general anaesthetic which was normal.