A 20-year-old man with treatment-resistant schizophrenia developed autonomic instability, hyperpyrexia and clouding of consciousness while on quetiapine. At the time he was maintained on 2.4 g sulpiride. The young man had been unwell for four years, initially in prison, the last 18 months in hospital. He suffered from a schizophrenic illness which was both severe and refractory. The situation was complicated by severe extrapyramidal side-effects with many antipsychotics and benign idiopathic neutropenia.

Sulpiride was started in March 1999, the dose in July increased to 2.4 g daily. Quetiapine was added in July 1999, to a dosage of 150 mg b.d. This was increased to 200 mg b.d. at the end of October. Compliance was assured.

In early November the patient developed a tachycardia; therefore, quetiapine was reduced to 150 mg b.d. In late November he was noted to be confused, flushed, tachycardic (130 beats per minute) and pyrexial (37.4°C). His creatine phosphokinase was 723 IU/l (range 55-120). There had been no other pharmacological interventions for 20 days.

A diagnosis of early neuroleptic malignant syndrome (NMS) was made. All antipsychotic medication was stopped and his physical symptoms resolved over 72 hours.

All antipsychotics can cause NMS (Reference BazireBazire, 1999). Sulpiride was introduced in the UK in 1983. Twenty-eight cases of NMS with sulpiride have been reported to the Committee on Safety of Medicines, seven cases with sulpiride alone have been published. Quetiapine was introduced in the UK in 1997. Four cases of NMS have been reported to the Committee on Safety of Medicines, one has been published to date (Reference Whalley, Diaz and HowardWhalley et al, 1999).

In this case, quetiapine is the more likely causative agent as the patient had been maintained on sulpiride for many months and the onset of symptoms was preceded by a recent change of quetiapine dosage.