Atypical First-Episode Psychosis with Prolonged Catatonia and Neuroleptic Malignant Syndrome: Diagnostic Challenges and Improvement with Clozapine: A Case Report and Literature Review

Abstract

Schizophrenia is a long-term mental illness that usually shows typical positive symptoms, but some patients have unusual symptoms that make diagnosis and treatment difficult. Catatonia and neuroleptic malignant syndrome (NMS) can occur in schizophrenia, yet atypical early-onset cases are not well described. This case explores the first episode of atypical psychosis with prolonged catatonia and NMS, focusing on diagnostic challenges and response to clozapine.
This case report describes a 24-year-old Hispanic male, admitted with unclear depression, suicidal thoughts, disorganized behavior, and unclear psychosis, without hallucinations or delusions. Later developed prolonged catatonia overlapped with NMS following treatment with antipsychotics. Extensive medical, neurologic, autoimmune, and infectious evaluations were negative. Multiple treatments, including benzodiazepines and several antipsychotics, resulted in minimal improvement. After failure of standard treatments for five months, clozapine was started and slowly increased, following guidelines. The patient showed marked improvement, including improved speech, behavior, affect, and participation in therapy. No significant adverse effects were reported.