Quetiapine misuse/overdose
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Various toxicities: case report A 28-year-old man developed compartment syndrome of the deltoid and pectoralis major, brachial plexus compression, neurological symptoms, acute renal failure, rhabdomyolysis and acute myositis following overdose and misuse of quetiapine for depression [not all outcomes stated]. The man had been receiving treatment with oral quetiapine 200mg at night for depression with concurrent administration of clomipramine for obsessive-compulsive disorder. He presented with compartment syndrome of his left deltoid and pectoralis major with brachial plexus compression. He reported increasing severe pain over the left anterior chest and left arm over 24h. He had received more than his usual dose of quetiapine (around 1200mg) around 12h before the onset of his symptoms. The reason for taking quetiapine overdose was low mood (drug misuse) due to social stressors. On arrival, an examination was significant with compartment syndrome of the pectoral and deltoid compartments along with symptomatic compression of his left brachial plexus. The left deltopectoral region was found to be grossly swollen and very tender on palpation. Neurological examination showed powers of 4/5 for C5/6/7 and 2/5 for C8/T1. His sensation was noted to be remarkably reduced, and he reported numbness to dermatomes C6-T1. Additionally, he had evidence of acute kidney injury secondary to rhabdomyolysis. Eventually, he was found to have developed acute renal failure. His creatine kinase level was 30074 U/L. An urgent CT scan demonstrated prominent swelling involving the whole of his left pectoralis major compartment with prominent subcutaneous oedema changes extending from the midsternal level to the antero-lateral shoulder along with oedema changes around the short head of his biceps as well as around his subclavian/axillary artery. He also exhibited neurological symptoms. The man underwent an urgent fasciotomy of the left pectoralis fascia and anterior deltoid fascia. Intraoperative findings were significant with acute myositis. His muscles were found to be bulging and tense. Histological evaluation of a sample of muscles confirmed the diagnosis of myositis, which was attributed to quetiapine overdose as he had no history of injury or trauma. After fasciotomy, his acute renal failure resolved completely, and the neurological symptoms showed remarkable improvement. Following 48h, the wound was able to be closed primarily due to intervening negative pressure dressing. He was reviewed daily by the psychiatric team, and he was discharged on his regular dose of quetiapine 200mg at night. After 3 weeks of surgery, his brachial plexus compression and the compartment syndrome significantly improved. Also, his power was 5/5 for C7-T1 myotomes, but some weakness persisted. Seewoogoolam G, et al. Compartment syndrome of the deltoid and pectoralis major in a young man following quetiapine use. ANZ Journal of Surgery 89: E335-E336, No. 803498504 7-8, Jul 2019. Available from: URL: http://doi.org/10.1111/ans.14468
0114-9954/20/1819-000
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