A 32-year-old woman comes to the emergency department due to swelling of the left arm over the last 24 hours. The patient drinks alcohol 2-3 times a week and uses intravenous heroin daily. She has no other chronic medical problems and takes no medications. Temperature is 37.8 C (100 F), blood pressure is 105/62 mm Hg, pulse is 92/min, and respirations are 16/min. Chest auscultation reveals clear lung fields and normal first and second heart sounds. The abdomen is soft and nontender. Examination of the extremities shows several needle marks. The left arm is erythematous and swollen as well as warm and tender to the touch. There is no joint swelling, and range of motion is normal in all joints. The patient is started on intravenous clindamycin. The next morning the swelling and pain are improved, but the patient reports "feeling miserable." She has nasal congestion, nausea, and abdominal cramps in addition to multiple episodes of vomiting and loose stools. On repeat examination, the patient is restless and reports aching muscles and joints. Blood pressure is 132/88 mm Hg, pulse is 102/min and regular, and respirations are 16/min. Laboratory results from time of admission (0 hours) and 24 hours later are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old woman comes to the emergency department due to swelling of the left arm over the last 24 hours.  The patient drinks alcohol 2-3 times a week and uses intravenous heroin daily.  She has no other chronic medical problems and takes no medications.  Temperature is 37.8 C (100 F), blood pressure is 105/62 mm Hg, pulse is 92/min, and respirations are 16/min.  Chest auscultation reveals clear lung fields and normal first and second heart sounds.  The abdomen is soft and nontender.  Examination of the extremities shows several needle marks.  The left arm is erythematous and swollen as well as warm and tender to the touch.  There is no joint swelling, and range of motion is normal in all joints.  The patient is started on intravenous clindamycin.  The next morning the swelling and pain are improved, but the patient reports "feeling miserable."  She has nasal congestion, nausea, and abdominal cramps in addition to multiple episodes of vomiting and loose stools.  On repeat examination, the patient is restless and reports aching muscles and joints.  Blood pressure is 132/88 mm Hg, pulse is 102/min and regular, and respirations are 16/min.  Laboratory results from time of admission (0 hours) and 24 hours later are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d496_27d1_bc81_9127aae68f3d_MD0003_00 This patient with a history of intravenous drug abuse presents initially with upper extremity cellulitis, which appears to respond appropriately to clindamycin, as noted by improved pain and resolution of leukocytosis. However, her new symptoms are suggestive of acute opioid withdrawal. Patients with opioid dependence typically develop withdrawal symptoms within 6-12 hours of the last dose of a short-acting opioid, with a peak 24-48 hours after symptom onset. Manifestations frequently include nausea, vomiting, cramps, diarrhea, restlessness, rhinorrhea, lacrimation, myalgias, and arthralgias. Examination can show hypertension, tachycardia, mydriasis, piloerection, and hyperactive bowel sounds. Although symptoms caused by natural opioid cessation (ie, not triggered by administration of an antagonist) are not life-threatening, they can be quite uncomfortable. Low-dose methadone, a long-acting opioid agonist, is often used in combination with adjunctive medications for symptom relief such as loperamide (diarrhea), ibuprofen (myalgias), baclofen (muscle cramps), and clonidine (anxiety, restlessness, hypertension). Under federal law, emergency management of opioid withdrawal with methadone is permitted for up to 3 days if the treatment is inpatient and the primary disease is medical (eg, cellulitis). This should not be confused with methadone replacement therapy for chronic outpatient addiction management, where regulations are different. (Choice A) Intravenous morphine should not be used in the management of opioid withdrawal. It is a potent, highly addictive, and short-acting opioid, and its use could be detrimental to the long-term goal of overcoming addiction. (Choice B) Clindamycin can be associated with diarrhea, nausea, vomiting, and anorexia. However, the patient's restlessness, arthralgias, and history of substance abuse are more suggestive of opioid withdrawal. (Choice C) Intravenous naloxone is a potent opioid antagonist used for patients with opioid intoxication. It can induce rapid withdrawal and should not be used in those who have withdrawal symptoms as it may cause acute worsening. (Choice E) Flumazenil is a benzodiazepine receptor antagonist and can be used in instances of benzodiazepine intoxication (which typically causes depressed mental status with slurred speech), but it has no use in the treatment of opioid withdrawal. (Choice F) Clostridium difficile infection typically occurs in hospitalized patients with antibiotic exposure and can cause abdominal cramps, nausea, and diarrhea. However, it is typically associated with leukocytosis (resolved in this patient), usually develops within 5-10 days of antibiotic use, and is unlikely to cause arthralgias. Educational objective: Common symptoms of opioid withdrawal include nausea, cramps, diarrhea, restlessness, rhinorrhea, lacrimation, myalgias, and arthralgias. Examination can show hypertension, tachycardia, mydriasis, piloerection, and hyperactive bowel sounds. Low-dose methadone with adjunctive medications is the treatment of choice. References: Treatment of Opioid-Use Disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27464203)

A 32-Year-Old Woman Comes to the Emergency Department Due to Swelling