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Background and Importance Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening adverse drug reaction, most frequently associated with antipsychotics. It typically presents with altered mental status, muscle rigidity, hyperthermia and autonomic dysfunction. In elderly patients, however, clinical manifestations may be atypical and less evident, delaying diagnosis. Hospital pharmacists play a role in supporting timely recognition and optimising pharmacological management.Aim and Objectives To report an atypical case of NMS in an 87-year-old institutionalised woman with advanced dementia, severe cognitive impairment, and high dependency. Her medical history included hypertension, type 2 diabetes mellitus, chronic atrial fibrillation, chronic kidney disease, dyslipidaemia, chronic anaemia, dysphagia, sacral pressure ulcer, and recent MRSA nasal colonisation. She was receiving long-term risperidone therapy for behavioural symptoms of dementia.Material and Methods The patient was admitted for dyspnoea, hypoxaemia, fever and a positive PCR test for influenza A. During hospitalisation she developed nocturnal agitation and received a single subcutaneous dose of haloperidol 2.5 mg. The following day, she presented with persistent fever (38 °C), unresponsiveness to verbal and motor stimuli, generalised rigidity and disorientation. Laboratory tests showed no creatine kinase elevation. After excluding alternative diagnoses, NMS was suspected as the fever did not respond to antipyretics, suggesting a central origin. Interventions included risperidone withdrawal, intravenous hydration, physical cooling measures and benzodiazepines. Intravenous diazepam was administered (initial 2.5 mg, titrated to 10 mg daily for 2 times).Results Following diazepam treatment, the patient progressively improved. Fever decreased gradually, rigidity lessened, and consciousness returned to baseline. Laboratory tests normalised, no infectious focus was identified, and blood cultures remained negative. After 1 week of stabilisation, she was discharged back to her nursing home.Conclusion and Relevance This case illustrates the diagnostic complexity of NMS in geriatric patients, where atypical presentations (absence of CK elevation, nonspecific symptoms) are common, especially in the presence of cognitive impairment, and may hinder timely recognition. A thorough medication history and a high index of suspicion are essential. A multidisciplinary approach involving physicians and pharmacists facilitated accurate diagnosis and tailored treatment. In emergency settings, neuroleptic use should be carefully evaluated due to potential clinical implications. Early recognition and adequate management are crucial to prevent complications and improve outcomes.Conflict of Interest No conflict of interest