A 58-year-old woman comes to the emergency department after developing a headache following a gourmet meal that included heavy sauces and wine. On arrival, the patient is anxious and tremulous. Medical history includes recurrent major depression with psychotic features, generalized anxiety disorder, and osteoarthritis. Medications include phenelzine and risperidone, which she takes as prescribed. Her depression has been in remission for the past 5 years. The patient's other medications include ibuprofen. She does not use illicit drugs. Which of the following is the most likely finding on physical examination?

Question

A 58-year-old woman comes to the emergency department after developing a headache following a gourmet meal that included heavy sauces and wine.  On arrival, the patient is anxious and tremulous.  Medical history includes recurrent major depression with psychotic features, generalized anxiety disorder, and osteoarthritis.  Medications include phenelzine and risperidone, which she takes as prescribed.  Her depression has been in remission for the past 5 years.  The patient's other medications include ibuprofen.  She does not use illicit drugs.  Which of the following is the most likely finding on physical examination?

Quizplus · Accepted Answer

The acute onset of headache following a meal in a patient treated with phenelzine raises concern for hypertensive crisis. Phenelzine is one of several available monoamine oxidase inhibitors (MAOIs), an older class of antidepressant drugs used primarily for the treatment of refractory depression. In the brain, they inhibit the metabolism of the monoamines norepinephrine, dopamine, and serotonin. MAOIs are not typically used as first-line therapy due to drug-drug interactions and dietary restrictions involving foods containing tyramine. Tyramine may be present in aged cheeses, aged or cured meats, aged or fermented soy products, overripe fruits, and some alcoholic beverages. Tyramine is a sympathomimetic monoamine that can facilitate the release of other sympathomimetic monoamines (eg, adrenaline/epinephrine) systemically. Tyramine metabolism is inhibited in the presence of MAOIs, causing an increased sympathomimetic (ie, adrenergic) effect that can result in severe hypertension. This commonly presents first as a headache but can lead to intracranial bleeding, stroke, and death. (Choices A and F) Hyperreflexia and myoclonus are characteristic of serotonin syndrome, which can occur when MAOIs are combined with serotonergic antidepressants, illicit substances, or other medications with serotonergic effects (eg, selective serotonin reuptake inhibitors, meperidine). The combination of an MAOI and tyramine does not usually result in serotonin syndrome. (Choice C) Hyperthermia is not a typical feature of hypertensive crisis. (Choice D) Hypotension is a fairly common side effect of MAOIs and may lead to dizziness but is not related to any dietary interaction. (Choice E) Diffuse muscle rigidity is seen in neuroleptic malignant syndrome, a rare medical complication of antipsychotics that typically occurs early in treatment and would be unlikely to appear in a patient who has been on a stable dose of risperidone for years. Educational objective: Patients taking monoamine oxidase inhibitors such as phenelzine should avoid foods rich in tyramine as the interaction of such food-drug combinations can result in hypertensive crisis. References: Dietary restrictions and drug interactions with monoamine oxidase inhibitors: an update. (http://www.ncbi.nlm.nih.gov/pubmed/22951238) Current place of monoamine oxidase inhibitors in the treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/23934742)

A 58-Year-Old Woman Comes to the Emergency Department After Developing