Ultrasound elastography in pediatric care: bridging innovation and noninvasive diagnostics.

Neuroleptic Malignant Syndrome (NMS) is an idiosyncratic, life-threatening reaction to antipsychotic medications, classically characterized by the tetrad of hyperthermia, muscular rigidity, altered mental status, and autonomic dysfunction. First described by Delay and Deniker in 1968, NMS remains a significant diagnostic and therapeutic challenge, particularly in its atypical presentations []. The incidence of NMS ranges from 0.02 to 3% among patients receiving neuroleptic medications, with mortality rates historically reported between 10 and 20%, though modern recognition and treatment have reduced this to approximately 5–10% [–]. Risk factors include dehydration, agitation, exhaustion, organic brain disease, and the use of high-potency typical antipsychotics [, ]. NMS diagnosis rests primarily on clinical assessment. According to DSM-5 criteria, the diagnosis requires antipsychotic exposure within the preceding 72 h, hyperthermia documented on at least two occasions, severe muscular rigidity, and the presence of at least two additional supportive features, which may include diaphoresis, dysphagia, tremor, incontinence, altered consciousness, mutism, tachycardia, labile or elevated blood pressure, leukocytosis, and elevated creatine kinase []. Systematic exclusion of alternative medical and neurological explanations is an integral component of the diagnostic process. Laboratory findings are non-specific but characteristically include elevated creatine kinase, leukocytosis, and raised serum transaminases; myoglobinuria may be present in severe cases, reflecting underlying rhabdomyolysis []. Because atypical or incomplete presentations may not satisfy all DSM-5 criteria, complementary frameworks have been developed to improve diagnostic sensitivity []. The Levenson criteria and the International Consensus Diagnostic Criteria (ICDC) for NMS both employ weighted scoring systems that evaluate core and supportive clinical features, allowing a probabilistic approach to diagnosis when the full classic tetrad is absent []. Atypical NMS presentations are increasingly recognized, particularly with second-generation antipsychotics and in elderly patients with multiple comorbidities []. These cases may present with incomplete symptom profiles, making early recognition crucial yet challenging. We report a case of atypical NMS in a geriatric palliative care patient successfully managed with alternative therapeutic approaches.