Bradley Ng

Serotonin syndrome following methylene blue infusion during parathyroidectomy : a case report and literature review

Purpose: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy; to advance the argument for a diagnosis of serotonin syndrome; and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue.Clinical features: Methylene blue was administered to a 58-yr-old woman undergoing a parathyroidectomy under general anesthesia. The patient had a background of obsessive compulsive disorder treated with paroxetine. Postoperatively, she demonstrated symptoms and signs of serotonin syndrome; specifically tachycardia, agitation, dystonia and abnormal eye movements. These clinical findings spontaneously resolved themselves over the subsequent 48 hr.Conclusion: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. Consideration should be given to avoiding methylene blue in patients taking serotonergic agents. The diagnosis should be considered in patients with autonomic, neuromuscular or neurological changes and should be managed accordingly.RésuméObjectif: Présenter un cas d’instabilité autonome, neurologique et neuromusculaire suivant une perfusion de bleu de méthylène pendant une parathyroïdectomie ; développer les assises du diagnostic de syndrome sérotoninergique ; reconsidérer, à la lumière de ce diagnostic, des cas précédents de réactions indésirables inexpliquées chez des patients ayant subi des parathyroïdectomies et traités avec du bleu de méthylène.Éléments cliniques : Du bleu de méthylène a été administré à une femme de 58 ans subissant une parathyroïdectomie sous anesthésie générale. La patiente présentait des antécédents de troubles obsessionnels compulsifs traités avec de la paroxétine. Après l’opération, elle a présenté des symptômes et signes d’un syndrome sérotoninergique, spécifiquement: tachycardie, agitation, dystonie et mouvements oculaires anormaux. Ces observations cliniques se sont résolues spontanément durant les 48 h suivantes.Conclusion : Une interaction entre le bleu de méthylène et les agents sérotoninergiques pourrait provoquer un syndrome sérotoninergique. Il faudrait considérer l’option d’éviter le bleu de méthy-lène chez les patients traités avec des agents sérotoninergiques. Ce diagnostic devrait être envisagé chez les patients présentant des modifications autonomes, neuromusculaires ou neurologiques et ils devraient être pris en charge en conséquence.

The improvement of obsessive– compulsive symptoms in a patient with schizophrenia treated with clozapine

The relationship between comorbid obsessive– compulsive symptoms (OCS) in schizophrenia and clozapine remains controversial. Case reports have described new onset or worsening OCS with clozapine treatment 1,2 and one study suggested that OCS may be more prevalent in clozapine-treated patients. 3 However, others have reported an improvement of OCS in patients with schizophrenia who are receiving clozapine 4,5 and one study failed to show increasing OCS in such patients. 6 We report a patient with schizophrenia whose pre-existing OCS improved with clozapine. The patient was a 20-year-old male with a history of schizophrenia complicated by the abuse of alcohol, cannabis and solvents since the age of 14 years. He had been discharged recently from an acute inpatient psychiatric unit, but was readmitted due to auditory hallucinations and suicidal ideation. He had abused solvents and had been non-compliant with his medication, which were quetiapine 300 mg BD and sodium valproate 1000 mg BD. In the unit he was observed to be clutching his throat while hyperextending his neck. This behavior had been noted in previous admissions but had not been considered a management problem. On this admission he would clutch his throat for 5–10 s and the frequency gradually increased to 50–60 times a day, resulting in permanent bruising on his neck around both carotid arteries. The patient stated that he experienced recurrent, persistent and intrusive thoughts of his childhood sexual abuse, which had been previously documented. He recognized these as his own thoughts and they distressed him because he would feel unclean and violated. In the community he would abuse solvents to suppress these thoughts. When he did not have access to solvents, he would respond by clutching his throat, resulting in his experiencing a ‘rush of blood to his head and butterflies in his stomach’, and then a range of emotions including happiness, anger, pleasure and sadness. He denied feeling sexually aroused. On this admission he admitted that this behavior had increased in frequency and would not necessarily be precipitated by thoughts of abuse. This behavior did not lead to any changes on electrocardiogram, ruling out carotid sinus massage. He was switched to clozapine (275 mg/day) and his psychotic symptoms subsided with a simultaneous reduction in his throat clutching behavior. On discharge he was clutching his throat only two to three times a day. He reported that his thoughts about his abuse had decreased in frequency, and consequently he did not feel the need to use solvents. He was discharged and remained symptom free for 18 months after discharge. During that period he did not have the urge to use solvents and clutched his throat three to four times on average per day. The patient had an established diagnosis of schizophrenia but did not meet DSM-IV criteria for posttraumatic stress disorder or obsessive–compulsive disorder (OCD). He had recurrent and intrusive memories of sexual abuse and he developed a repetitive behavior to reduce the subsequent distress. In the community he would use solvents to reduce these thoughts, but this was unavailable in an inpatient setting. These OCS subsided as his psychotic symptoms improved with clozapine. Case reports have described OCS subsiding in patients with chronic schizophrenia on 75–300 mg/day of clozapine. 4,5 One retrospective study of 142 inpatients found no definitive cases of patients who developed or worsening of pre-existing OCD on clozapine. 6

Rehabilitating ECT's public image

high prevalence of nicotine dependence within this patient population, the importance of cigarettes as currency among psychiatric patients and the stringent non-smoking policies enforced by hospitals has increased the practice of patients smoking outside hospital settings. The likelihood of finding discarded cigarettes among potting soil increases the possibility of the unhygienic practice of smoking used cigarettes.