Title: Severe Extra Pyramidal symptoms vs Neuroleptic Malignant Syndrome following long acting depot formulation of typical antipsychotic- a diagnostic dilemma and its management: a case report.

BACKGROUND: Flupenthixol Decanoate is a long acting typical antipsychotic which mainly acts as an antagonist of central D2 receptors but the chances of both EPS and NMS are high with its use.In this case report we are going to discuss how challenging it might be sometimes to differentiate between severe EPS and NMS due to some of its overlapping symptoms and dramatic presentation and how to manage promptly to prevent ICU admission and subsequent mortality. CASE: Here, we are reporting this unique case of a 19 years old boy belonging from lower middle Socio- economic status, residing in urban area, who developed severe EPS like tremors, severe rigidity, sialorrhea, dystonia, occulogyric crisis, akathisia following administration of long acting injection of Flupenthixol deacanoate at a high dose and was on the verge of progression to full blown NMS, and how it improved by timely intervention with appropriate combination of Dopamine agonists, anticholinergics and conservative management. CONCLUSION: Our study explains that by prompt recognition of symptoms and timely intervention by appropriate agents, progression of severe EPS to NMS can be prevented and hence the mortality can be reduced and quality of life can be improved.Our study also emphasizes on certain aspects which has to be kept in mind by mental health professionals during use of typical LAIs to prevent serious consequences.