A 37-year-old man is admitted to the hospital for right lower-lobe pneumonia. He is given antibiotics, and his shortness of breath and fever improve by the second hospital day. However, he now has new-onset abdominal pain, diarrhea, and severe muscle aches. The patient has no history of gastrointestinal conditions or prior surgeries but does admit to recreational drug use. Temperature is 36.8 C (98.2 F), blood pressure is 124/80 mm Hg, and pulse is 88/min. On examination, the patient appears uncomfortable and anxious. Pupils are dilated and there is prominent lacrimation. Abdominal examination reveals hyperactive bowel sounds without tenderness or distension. Which of the following is the most likely diagnosis?

Question

A 37-year-old man is admitted to the hospital for right lower-lobe pneumonia.  He is given antibiotics, and his shortness of breath and fever improve by the second hospital day.  However, he now has new-onset abdominal pain, diarrhea, and severe muscle aches.  The patient has no history of gastrointestinal conditions or prior surgeries but does admit to recreational drug use.  Temperature is 36.8 C (98.2 F), blood pressure is 124/80 mm Hg, and pulse is 88/min.  On examination, the patient appears uncomfortable and anxious.  Pupils are dilated and there is prominent lacrimation.  Abdominal examination reveals hyperactive bowel sounds without tenderness or distension.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3632_e872_9249_8f4247d1b5da_MD0001_00 This patient is experiencing the classic symptoms of opioid withdrawal. Opioid withdrawal can start as soon as 6-12 hours after cessation of a short-acting opioid such as heroin and usually peaks within 24-48 hours. Symptoms include nausea, vomiting, diarrhea, abdominal cramping, and myalgia. It is generally nonlife-threatening and vital signs are usually normal. Dilated pupils, prominent piloerection, and hyperactive bowel sounds are seen on examination. Opioid withdrawal can appear similar to other withdrawal or intoxication syndromes, but certain findings, including lacrimation and yawning, are fairly specific. Individuals who have been taking chronic prescription opioids, such as cancer patients, can also develop opioid withdrawal on abrupt discontinuation or marked reduction in usage. (Choices A and D) Alcohol and benzodiazepine withdrawal are two of the few potentially fatal drug withdrawal syndromes. Symptoms of alcohol withdrawal typically begin after 12-24 hours and are typified by autonomic hyperactivity (eg, tremors, agitation, diaphoresis, tachycardia, hypertension). Onset of benzodiazepine withdrawal depends on the half-life of the specific agent and is characterized by tremors, anxiety, perceptual disturbances, dysphoria, and psychosis. Alcohol and benzodiazepine withdrawal may also lead to seizures. (Choices B and E) Amphetamine and cocaine intoxication are marked by euphoria, increased vigilance, psychomotor agitation, tachycardia, hypertension, and hyperthermia. As in opioid withdrawal, pupils are dilated with stimulant intoxication. However, this patient's gastrointestinal upset and lacrimation are more typical of opioid withdrawal. (Choice C) Antibiotic use may be associated with diarrhea and other adverse effects. However, this patient's history of recreational drug use and relatively specific signs of opioid withdrawal (eg, lacrimation) make opioid withdrawal more likely. (Choice F) Nicotine withdrawal is commonly seen in the inpatient setting in chronic tobacco users. Besides cravings for cigarettes, symptoms are generally mild and include dysphoria, irritability, anxiety, and increased appetite/weight gain. (Choice H) Viral gastroenteritis is characterized by diarrhea, vomiting, and fever. Educational objective: Opioid withdrawal is marked by mydriasis, abdominal pain, diarrhea, piloerection, lacrimation, and yawning. It is generally nonlife-threatening, unlike withdrawal from alcohol and benzodiazepines. __________ References: Update on pharmacotherapy for treatment of opioid use disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27734745) Buprenorphine for the management of opioid withdrawal. (http://www.ncbi.nlm.nih.gov/pubmed/19588330)

A 37-Year-Old Man Is Admitted to the Hospital for Right