He was reviewed on day 7 by psychiatry and was relaxed, coherent and appropriate. There was no evidence of any ongoing psychotic symptoms or abnormal movements. He scored 27/30 on the Mini-Mental State Exam (MMSE). When reviewed on day 11 he remained well. Mood was euthymic and he scored 30/30 on the MMSE.

There were no psychotic symptoms. The likely diagnosis of NMS was explained to the patient and both venlafaxine and quetiapine discontinued completely, only to be recommenced in future with marked caution and under strict supervision. Discussion We believe that the above case adds to the literature base describing NMS in association with both Inhibitors,research,lifescience,medical quetiapine and venlafaxine. It is acknowledged that there exists no universally accepted set of diagnostic criteria for NMS and that there is considerable overlap of features between NMS and serotonin syndrome, allowing Inhibitors,research,lifescience,medical for significant diagnostic blurring [Sachdev, 2005]. We believe that in this case the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for NMS were satisfied given the presence of muscle rigidity and elevated temperature accompanied by diaphoresis, altered consciousness,

tachycardia, labile blood pressure, leukocytosis Inhibitors,research,lifescience,medical and markedly elevated CK [American Psychiatric Association, 2000]. The slow duration of onset and recovery are felt to be more suggestive of a diagnosis of NMS than serotonin syndrome [Susman, 2001]. The recent stability in the patient’s medication regime, the history of opioid dependence and hepatitis C status and the prescription of the second-generation antipsychotic quetiapine are Inhibitors,research,lifescience,medical at odds with Sternbach’s criteria for a diagnosis of serotonin syndrome which include a recent change in a potent serotonergic agent, the absence of a history of substance misuse or infectious (or metabolic) disease and the absence of an antipsychotic agent [Sternbach, 1991]. Prominent autonomic instability and the presence of a leukocytosis Inhibitors,research,lifescience,medical lend further support

to the diagnosis of NMS [Marlowe and Schirgel, 2006]. NMS has been described with all second-generation antipsychotics such as quetiapine, including those even the recently licensed preparation asenapine [Singh and Wise, 2010]. It has also been described in selleckchem several cases of antipsychotics being prescribed in combination with both selective serotonin reuptake inhibitor (SSRI) and serotonin–norepinephrine reuptake inhibitor (SNRI) antidepressants, the latter class of which includes venlafaxine [Stevens, 2008]. In their recent comparison of NMS induced by first- and second-generation antipsychotics, Trollor and colleagues noted a high rate of concurrent prescription of serotonergic antidepressants in their sample [Trollor et al. 2012].