Board Review

Interesting Bored Review

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So you get this guy, 23 yo M with schizophrenia and depression brought to ED by Mom for “acting strange”. Mom reports a recent change in his psychiatric medication, but does not know the specifics.

Patient is agitated and not responding to your questions appropriately

VS: T 103.8, HR 120, RR 23, BP 200/120, 100% on RA

PE: does not follow commands, diaphoretic, tremulous, shivering, with occasional myoclonus.

 

Diagnosis?

NOT SEPSIS. I know he meets SIRS criteria. BUT STOP ANCHORING. It’s Serotonin Syndrome (one of my favorite sepsis mimics)

How do you diagnose?

Clinically – on serotonin agent with a spectrum including: muscle rigidity, AMS (can be agitated or coma), fever, hyper-reflexia, myoclonus, diarrhea, tachycardia, hyper or hypotension. The clinical picture is similar to thyroid storm!

How do you treat?

Supportive care. Decrease muscle rigiditiy with benzos. In severe cases, neuromuscular blockade and cyproheptadine.

What related syndrome should be considered?

NMS: neuroleptic malignant syndrome. NMS usually presents days to weeks after starting the offending agent and has less shivering, tremulousness, and agitation; the characteristic “lead pipe” muscular rigidity and bradykinesia are often seen.

 

By Dr. Andrew Grock, Dr. Sally Bogoch, and guest co-author Dr. Nathan Reisman

 

References

Golfrank’s toxicology, 9th ed

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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andygrock

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