A 21-year-old man is brought to the emergency department by ambulance because of unusual behavior that started 3 hours ago while he was at a party. He has a history of major depressive disorder and seasonal allergies. His mother has a history of anxiety. He drinks 5 beers on the weekends. Current medications include amitriptyline and diphenhydramine. The patient does not respond to questions and repeatedly says, “The government is following me everywhere.” His temperature is 37.9°C, pulse is 115/min, respirations are 24/min, and blood pressure is 160/89 mm Hg. He is diaphoretic. He is not oriented to place or time. Neurologic examination shows dilated pupils bilaterally and diffuse hyperreflexia. His feet are cold, and capillary refill time is 3 seconds. After the examination, the patient starts screaming and tries to bite the physician. Urine toxicology screening is positive for ethyl glucuronide. Which of the following is the most likely explanation for this patient’s symptoms?
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Correct Answer � D
Explanation
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Synthetic cathinone intoxication
Anticholinergic toxicity
Anticholinergic toxicity can cause hyperthermia, tachycardia, mydriasis, and altered mental status. This diagnosis should be considered in this patient, who takes amitriptyline and diphenhydramine, both of which have anticholinergic effects. However, anticholinergic toxicity typically also causes anhidrosis (not diaphoresis), peripheral vasodilation (not vasoconstriction), and urinary retention (which is not reported here).
Delirium tremens
Delirium tremens (DT) can manifest with tachycardia, hypertension, hyperreflexia, agitation, and altered mental status. DT occurs in individuals who have a long-standing history of alcohol use disorder and should be considered in this patient, who reports drinking 5 beers on weekends and has a urine toxicology screening that is positive for ethyl glucuronide. However, this patient does not have a tremor, which is a classic manifestation of DT. In addition, mydriasis is not commonly seen in patients with DT.
Lysergic acid diethylamide intoxication
Lysergic acid diethylamide (LSD) is a synthetic hallucinogenic drug that can cause altered mental status. Although LSD intoxication commonly manifests with symptoms of sympathetic activation (e.g., hyperthermia, tachycardia, hypertension, diaphoresis, mydriasis, peripheral vasoconstriction), these findings are usually milder than those seen in this patient. In addition, LSD intoxication commonly manifests with optical hallucinations and/or illusions and is less likely to cause violent behavior (e.g., screaming and biting) than another drug.
Additional Information
LSD cannot usually be detected with routine urine toxicology screening.
Synthetic cathinone intoxication
Synthetic cathinones, also known as “bath salts,” are recreational drugs that are similar to amphetamines. Synthetic cathinone intoxication typically causes manifestations of sympathetic stimulation (e.g., hyperthermia, tachycardia, hypertension, diaphoresis, mydriasis, peripheral vasoconstriction) and markedly altered mental status, as seen in this patient. Classic neuropsychiatric manifestations of this condition include aggression, hallucinations, paranoia, and confusion. Many synthetic cathinones cannot be detected with routine urine toxicology screening. The diagnosis of synthetic cathinone intoxication is made based on history and observed clinical features.
This patient’s urine toxicology is positive for ethyl glucuronide, a metabolite of ethanol, which indicates the patient has also likely ingested alcohol.
