Antipsychotics
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CNS disorders following drug-withdrawal: case report A man in his 20s [exact age at reaction onset not stated] developed delirium, catatonia, generalised tonic-clonic seizure, focal clonic seizures, and nonconvulsive status epilepticus (NCSE) following withdrawal of lorazepam. Additionally, the catatonia exacerbated following treatment with trazodone, venlafaxine and olanzapine for a schizoaffective disorder of depressed type with catatonia [routes and durations of treatment to reaction onset not stated]. The man, who had a history of schizoaffective disorder of depressed type with catatonia for 2 years, presented with seizures, delirium and catatonia. He had been receiving olanzapine 10mg, venlafaxine 300mg, and trazodone 100mg daily for about 1 year. About 1 year before admission, he fell at work and developed sustained concussion. In the past, he had several visits to hospital, for catatonia. He was commenced lorazepam 2mg twice daily, after which catatonia diminished for 6 months. However, he ran out of lorazepam 10 days before admission. After 3 days, he became less active and showed increased withdrawal. He assumed abnormal postures and appeared stiff after another 3 days. He was subsequently transferred to the emergency room after he was found soaked with urine, moaning and down facing towards the ground. On arrival, he was diaphoretic, tachycardiac (142–160/min) and hypotensive (80/50mm Hg); however, he was normothermic (37°C). Subsequent IV fluid administration decreased HR (118–132/min) and increased BP (132–142/74–90mm Hg). He exhibited waxy flexibility, psychomotor retardation and catalepsy. He showed minimal response towards verbal instructions and noxious stimulation. Deep tendon reflexes were prominent (3+) with rigidity in all the limbs. Bilateral ankle clonus was observed, which was consistent with generalised tonic-clonic seizure. Blood tests revealed elevated creatine kinase and mild hyperammonaemia. CSF analysis showed mildly increased protein. His home medications including trazodone, venlafaxine and olanzapine were withheld due to suspicion of neuroleptic malignant syndrome (NMS) and toxic serotonin syndrome (TSS). Subsequent EEG performed in the emergency room showed 25–115 second episodes of high-voltage generalised rhythmic delta activity (GRDA) alternating with 12–72 second episodes of non-GRDA background activity with a low-voltage beta, alpha and theta rhythms and rare delta waves. Minor changes in GRDA amplitude and frequency was observed with 2.5Hz as average frequency. He was administered IV lorazepam 2mg, and within 10 minutes, GRDA was replaced by low-voltage semi rhythmic theta and intermittent rhythmic beta activity. Furthermore, waxy flexibility and catalepsy disappeared. His condition improved, which suggested that he was in NCSE. He also had 10–20 second episodes of rhythmic right leg jerking, which was consistent with focal clonic seizures. The man was started on levetiracetam administration. However, catatonia recurred which required intervention with lorazepam administr
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