A 14-year-old boy is brought to the emergency department by a teacher after being found staggering and falling on the ground in the school parking lot between classes. When she found him, the patient seemed lethargic and disoriented and his speech was slurred. His condition slowly improved over the next 30 minutes; when the patient is evaluated in the emergency department an hour after the teacher found him, he is alert, oriented, and able to speak clearly. Temperature is 36.7 C (98.1 F), blood pressure is 102/65 mm Hg, and pulse is 62/min. On physical examination, there are abrasions on the right forearm and shin and a rash around the nostrils and mouth. The patient has no known medical history. Which of the following substances is the most likely cause of this patient's symptoms?

Question

A 14-year-old boy is brought to the emergency department by a teacher after being found staggering and falling on the ground in the school parking lot between classes.  When she found him, the patient seemed lethargic and disoriented and his speech was slurred.  His condition slowly improved over the next 30 minutes; when the patient is evaluated in the emergency department an hour after the teacher found him, he is alert, oriented, and able to speak clearly.  Temperature is 36.7 C (98.1 F), blood pressure is 102/65 mm Hg, and pulse is 62/min.  On physical examination, there are abrasions on the right forearm and shin and a rash around the nostrils and mouth.  The patient has no known medical history.  Which of the following substances is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

This patient's initial symptoms (eg, lethargy, ataxia, disorientation, slurred speech) followed by rapid improvement and a perioral and perinasal rash on examination are most likely due to inhalant use disorder. Inhalants, in the form of glue, toluene, nitrous oxide, amyl nitrite, and spray paints, are often the first drugs that adolescents misuse as they are inexpensive and readily available. They may be inhaled from a saturated cloth held near the face, from a bag placed over the nose and mouth, or by sniffing directly. A dermatitis known as "glue sniffer's rash" may be seen around the mouth or nostrils of chronic users. Inhalants cause immediate effects as they are highly lipid soluble and act as CNS depressants. They can produce brief transient euphoria, lethargy, disorientation, loss of consciousness, poor coordination, and slurred speech. Effects typically last 15-45 minutes. Severe complications include cardiac dysrhythmias, dangerous behavior, seizures, and death. Nitrous oxide misuse in particular is associated with vitamin B₁₂ deficiency and resultant symptoms of polyneuropathy (eg, symmetric numbness, gait abnormalities). (Choices A and B) Although alcohol and benzodiazepine use can cause similar mental status changes, this patient's rapid improvement and facial rash are more consistent with inhalant use disorder. Alcohol and benzodiazepine intoxication would likely result in a significantly longer period of intoxication. (Choice C) Cocaine is a CNS stimulant that typically produces euphoria, increased arousal, psychomotor agitation, tachycardia, and hypertension. It would not explain this patient's lethargy and ataxia. (Choice E) Classic signs of opioid intoxication include depressed mental status, respiratory depression, and miosis. The time course of symptoms and facial rash make inhalant use disorder a better explanation for this patient's symptoms. (Choice F) Phencyclidine (ie, PCP) intoxication is characterized by nystagmus, altered mental status, and agitated or violent behavior. Educational objective: Inhalant intoxication is characterized by immediate onset of euphoria, lethargy, ataxia, and/or loss of consciousness followed by rapid recovery within 45 minutes. Perioral and perinasal dermatitis (ie, "glue sniffer's rash") may be seen in chronic users. __________ References: Inhalant abuse and dextromethorphan. (http://www.ncbi.nlm.nih.gov/pubmed/27338970) Adolescent inhalant use prevention, assessment, and treatment: a literature synthesis. (http://www.ncbi.nlm.nih.gov/pubmed/26969125)

A 14-Year-Old Boy Is Brought to the Emergency Department by a Teacher