A 35-year-old man with a history of bipolar and substance use disorders comes to the emergency department due to depression, auditory hallucinations, and suicidal ideation. His medications include lithium and escitalopram. The patient has a history of 5 psychiatric hospitalizations and 2 past suicide attempts, including overdose on his medications and attempted hanging. He has a history of alcohol, benzodiazepine, heroin, and cocaine abuse. The patient has been using "anything I can get my hands on" because his depression is unbearable. He is hospitalized and placed on suicide precautions. His dose of escitalopram is increased to target his depression, and risperidone is added to treat the hallucinations. His lithium level is 1.0 mEq/L. On the second day of hospitalization, the patient reports muscle pains, abdominal cramping, nausea, and diarrhea. His temperature is 37.2 C (99 F), blood pressure is 130/85 mm Hg, and pulse is 84/min. The patient is alert and restless, and his pupils are dilated bilaterally. Bowel sounds are hyperactive and neurologic examination is normal. Which of the following is the most likely explanation for his symptoms?

Question

A 35-year-old man with a history of bipolar and substance use disorders comes to the emergency department due to depression, auditory hallucinations, and suicidal ideation.  His medications include lithium and escitalopram.  The patient has a history of 5 psychiatric hospitalizations and 2 past suicide attempts, including overdose on his medications and attempted hanging.  He has a history of alcohol, benzodiazepine, heroin, and cocaine abuse.  The patient has been using "anything I can get my hands on" because his depression is unbearable.  He is hospitalized and placed on suicide precautions.  His dose of escitalopram is increased to target his depression, and risperidone is added to treat the hallucinations.  His lithium level is 1.0 mEq/L.  On the second day of hospitalization, the patient reports muscle pains, abdominal cramping, nausea, and diarrhea.  His temperature is 37.2 C (99 F), blood pressure is 130/85 mm Hg, and pulse is 84/min.  The patient is alert and restless, and his pupils are dilated bilaterally.  Bowel sounds are hyperactive and neurologic examination is normal.  Which of the following is the most likely explanation for his symptoms?

Quizplus · Accepted Answer

11ec25c8_d7da_5682_bc81_a1d134bc9788_MD0003_00 The development of myalgias, nausea, diarrhea, abdominal cramping, hyperactive bowel sounds, and pupillary dilation on the second day of hospitalization is most consistent with opioid withdrawal. Withdrawal may begin 6-12 hours after cessation of a short-acting opioid and 24-48 hours after the last dose of methadone. Other typical symptoms include irritability, yawning, piloerection, rhinorrhea, and lacrimation. Patients are usually afebrile and alert and oriented. Although uncomfortable, opioid withdrawal is rarely dangerous. Treatment involves supportive care and medications (alpha-2 adrenergic agonists, methadone, or buprenorphine). (Choices A and B) This patient does not exhibit significant elevation in pulse and blood pressure, tremulousness, and diaphoresis, which would be more characteristic of alcohol or benzodiazepine withdrawal. If untreated, alcohol or benzodiazepine withdrawal is medically dangerous with potential for seizures, psychosis, and delirium. This patient's myalgias, diarrhea, and dilated pupils are more suggestive of opioid withdrawal. (Choice C) Cocaine withdrawal is characterized by depression, fatigue, and vivid dreams, but it typically has minimal physical symptoms. (Choice D) Lithium intoxication presents with coarse tremors, ataxia, altered mental status, nausea, vomiting, and diarrhea. It is more likely to occur at lithium levels above the therapeutic range (ie, >1.2 mmol/L). > (Choice E) Neuroleptic malignant syndrome is a potentially life-threatening idiosyncratic reaction to dopamine antagonists (eg, antipsychotics) and typically presents with high fever, generalized muscle rigidity, autonomic instability, and mental status changes. (Choice G) Although this patient does have hyperactive bowel sounds and dilated pupils, which can be seen in serotonin syndrome, he does not show other classic symptoms such as neuromuscular hyperactivity (eg, hyperreflexia, tremor, myoclonus), hypertension, tachycardia, and hyperthermia. Opioid withdrawal is more likely. Educational objective: Opioid withdrawal is characterized by myalgias, gastrointestinal symptoms, piloerection, pupillary dilation, irritability, yawning, and lacrimation. Temperature is usually normal and delirium is uncommon.

A 35-Year-Old Man with a History of Bipolar and Substance