The hot patient: acute drug-induced hyperthermia

The broad spectrum of malignant syndromes

Malignant syndromes represent a group of medical conditions characterized by a rapid evolution of clinical manifestations, potentially leading to life-threatening complications if left untreated. These syndromes pose significant challenges for diagnosis and management, as they can lead to multisystem organ failure and death. Despite distinct features and origins, these syndromes share similar clinical presentation, pathophysiology, and the imperative for urgent medical intervention. While distinct mechanisms may initially trigger the different malignant syndromes, a final common pathway leading to similar signs and symptoms involves various neurotransmitter systems, including dopaminergic, serotonergic, GABAergic, glycinergic, and glutamatergic pathways. This narrative review examines the clinical presentations and potential causes of malignant syndromes, both highlighting shared pathophysiological mechanisms and emphasizing the critical importance of early recognition and intervention to mitigate potentially fatal outcomes. Although clinically heterogeneous, with variable motor and non-motor manifestations, most malignant syndromes share acute and rapid disruptions in physiological functions, including body temperature regulation, metabolism, control of the autonomic system and maintenance of consciousness. The potential for severe morbidity and mortality associated with these syndromes emphasizes the critical need for understanding their clinical characteristics, underlying mechanisms, and appropriate management strategies.

Impact of Safinamide on Patient-Reported Outcomes in Parkinson's Disease

Introduction

Parkinson's disease (PD) is a chronic and progressive neurodegenerative condition due to the degeneration of nigral dopaminergic cells. Both motor and non-motor symptoms (NMS) of PD produce a marked impairment in PD patients' quality of life (QoL), but contrary to motor features, NMS do not improve with dopamine replacement. Novel therapeutic interventions for PD have successfully controlled most motor manifestations of PD, but the management of NMS is still challenging. Since NMS have a negative impact on the QoL of PD patients, researchers are currently looking for drugs that can modulate the activity of neurotransmitter systems other than dopamine in the hope that can alleviate NMS in PD. Among the recently approved drugs for patients experiencing fluctuations in motor symptoms, safinamide stands out as an effective add-on therapy to levodopa. Safinamide is a monoamine oxidase type-B inhibitor (MAOB-I), with proven efficacy in reducing motor fluctuations. Its distinctive mechanism of action impacts dopaminergic pathways via MAOB inhibition and glutamatergic pathways by blocking sodium and calcium channels. Findings from Phase III clinical trials, meta-analysis, post-hoc analysis, and real-life experiences indicate that safinamide benefits motor symptoms such as tremor, bradykinesia, rigidity, and gait. Additionally, it shows promise for improving NMS like fatigue, pain, mood, and sleep disturbances in patients with PD.

Areas Covered

In this article, the authors explore the impact of safinamide on patient-reported outcomes in PD. A thorough search was conducted on PubMed focusing on studies published between 2018 and 2023 in English. The inclusion criteria encompassed clinical trials, randomized controlled trials, systematic reviews, meta-analyses, and reviews. The search strategy revolved around the implementation of MeSH terms related to safinamide and its impact on the quality of life in PD.

Conclusion

Our data strongly support the improving effect on QoL, reducing the disabling NMS reported in patients with PD.

Neuroleptic malignant syndrome secondary to olanzapine, a presentation with severe acute kidney injury requiring hemodialysis: a case report

Background

We present this case to draw attention to the importance of early diagnosis in terms of life-saving, noting that greater awareness is important among healthcare professionals. Our patient developed neuroleptic malignant syndrome (NMS) after his neuroleptic drug dosage was increased. His condition was complicated by acute kidney injury (AKI) which required hemodialysis. The uniqueness of this case is that the causative agent of NMS is an atypical antipsychotic, and atypical antipsychotics are generally considered to be safer than typical antipsychotics.

Case presentation

A 31-year-old Chinese man with underlying schizophrenia presented to our hospital with aggressive behavior. He was admitted to the psychiatric hospital and started on his regular medications, with an increase in the dose of olanzapine tablet from 5 to 10 mg daily. After 5 days in the ward, the patient was noted to have high fever, restlessness, confusion, increased muscle rigidity, tachycardia and tachypnoea. Antipsychotic therapy was stopped in view of suspected NMS. The first laboratory test for serum creatine kinase (CK) showed a markedly high level of this molecule. His renal profile showed raised serum creatinine in comparison to 2 months prior when the baseline serum creatinine was within the normal range. A diagnosis of NMS with AKI was made. Although the patient was given adequate intravenous fluid hydration with close monitoring of urine output, his renal function did not show improvement but continued to show a worsening trend. In view of this, he was started on urgent hemodialysis. The patient was dependent on intermittent hemodialysis before his AKI showed complete recovery. After 2 weeks, his blood test results returned to normal. He was discharged well.

Conclusion

Neuroleptic malignant syndrome is a life-threatening iatrogenic medical emergency in which high index of clinical suspicion is required for diagnosis and prompt treatment.

High risk and low prevalence diseases: Serotonin syndrome

INTRODUCTION

Serotonin syndrome is a rare, frequently misdiagnosed, serious condition with high morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of serotonin syndrome, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Serotonin syndrome is a potentially deadly toxidrome marked by excess serotonin receptor activity or neurotransmission. Features of serotonin syndrome include 1) neuromuscular excitation such as tremor, hyperreflexia, and clonus; 2) autonomic dysfunction such as tachycardia, hypertension/hypotension, and hyperthermia; and 3) altered mental status such as agitation, delirium, and coma. Although serotonin syndrome may be more obvious in patients who have overdosed on serotonergic agents such as serotonin reuptake inhibitors (SSRIs), multiple other medications may also cause serotonin syndrome. Alternative diagnoses such as sepsis, neuroleptic malignant syndrome, and decompensated hyperthyroidism should be considered. The primary components of therapy include stopping the offending agent and supportive care, which focuses on agitation control, monitoring for and treating hyperthermia, and managing autonomic instability.

CONCLUSIONS

An understanding of serotonin syndrome can assist emergency clinicians in diagnosing and managing this disease.

Party keepers: a significant community-based intervention for harm reduction

Background

Gay men use recreational drugs more often than heterosexuals—especially at social events. While partying at a venue, partygoers are at risk of drug overdosing, without access to an emergency help. This study evaluates a unique and novel intervention aimed at training men who have sex with men (MSM) and transgender individuals who frequent parties, to provide immediate assistance on-site to partygoers who have overdosed.

Methods

The Party Keepers (PK) course is a unique 4-h training course that provides the participants with tools to identify, prevent, and treat common medical syndromes that are associated with excessive substance use. Participants were asked to complete a questionnaire on their sociodemographic attributes; their sexual risk behaviour; pre-exposure prophylaxis (PrEP) use and drug-use behaviour before and after the course; and the emergency situations they encountered in party venues after the course.

Results

Of the 85 participants who completed the training and left valid contact information, 52 (62%) completed the questionnaires. Their average age was 37.0 years, most lived in Tel-Aviv, and were single. Participants reported that, after the course, they reduced their own use of recreational drugs (cocaine, amyl nitrates, alcohol), reduced their sexual risk behaviours, and significantly increased their use of PrEP. Of all the PKs, 63% (N = 32) indicated that they now provided first-aid and other assistance to partygoers at public venues, which enhanced their sense of community responsibility. In the multivariate analysis, a high level of confidence as a PK, and the knowledge gained in the course, predicted the incidence of subsequent assistance to partygoers in emergency situations.

Conclusions

The PK initiative—a harm-reduction intervention led by peers, aimed at fighting drug overdosing at gay venues—was useful in reducing drug use and sexual risk behaviours among the course participants. Most course participants also responded to drug-related emergency situations at gay parties, as a result. This evaluation of community health intervention within a sexual minority community can help health policy makers design more community based interventions and allocate resources to include community participants in harm-reduction policies.

Morphine-Induced Fever: A Case Series

The most common cause of postoperative fever is infection. Other causes include cancer, iatrogenic causes, venous thromboembolism, secondary to prosthetic implants, and pyrexia of unknown origin. Here, we describe five cases of opioid-induced pyrexia. In all cases, an injection of morphine was given for postoperative analgesia and all those patients developed fever. All the possible causes of fever were excluded and then opioid was substituted with non-steroidal anti-inflammatory agents. Fever subsided in all the cases. Cessation of the offending drug led to the resolution of the fever in all five cases, and the patient required subsequent supportive care. However, adjunctive pharmacotherapy may also be needed in some patients.

A sabbath in the emergency room or a case of anticholinergic toxicity?

We report the case of a 32-year-old Italian man admitted to our emergency room for visual disturbances with blurred vision, anisocoria and temporal headache suddenly occurred in absence of other neurological symptoms. A diagnosis of Datura stramoniuminduced anticholinergic toxicity was done. With our work, we want to highlight the importance of a meticulous clinical examination, including papillary diameter and reflexes, combined with a detailed history of the patient in the emergency room. Anticholinergic toxicity is a medical emergency. The diagnosis is always clinical, and it can represent a challenge for the emergency clinicians because it can mimic several neurological diseases, including acute stroke and seizures, but early diagnosis is crucial to avoid severe complications and management errors.

Global warming, heat-related illnesses, and the dermatologist

Global warming, provoked by the greenhouse effect of high levels of atmospheric gases (most notably carbon dioxide and methane), directly threatens human health and survival. Individuals vary in their capacity to tolerate episodes of extreme heat. Because skin is the organ tasked with heat dissipation, it is important for dermatologists to be versed in the physiology of cutaneous heat dissipation and cognizant of clinical settings in which the skin’s thermoregulatory responses may be impaired. When the external temperature is lower than that of the skin, the skin releases internal heat through direct thermal exchange with the environment, a process that is aided by an expansion of cutaneous blood flow and eccrine sweating. Cooling through the evaporation of sweat is effective even when the external temperature exceeds that of skin. Many factors, including environmental and physiological (e.g., age and sex), and pathological (e.g., preexisting illnesses, disorders of eccrine function, and medications) considerations, affect the skin’s capacity to thermoregulate. Identification of individuals at increased risk for heat-related morbidity and mortality will become increasingly important in the care of patients.

Suspected Overlap Between Serotonin Syndrome and Neuroleptic Malignant Syndrome in a Child Treated With Metoclopramide?

A 19-month-old child presented with fever and acute neurological deterioration with hypertonia, tremors, and clonus 1 day after starting metoclopramide. The clinical course of the patient was suggestive of neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS), which can both be triggered by metoclopramide. This first pediatric report of an overlap between NMS and SS associated to metoclopramide highlights the importance of considering this new entity and its consequences on treatment.

[Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]

The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.

Hepatic Metabolic Derangements Triggered by Hyperthermia: An In Vitro Metabolomic Study

BACKGROUND AND AIMS

Liver toxicity is a well-documented and potentially fatal adverse complication of hyperthermia. However, the impact of hyperthermia on the hepatic metabolome has hitherto not been investigated.

METHODS

In this study, gas chromatography-mass spectrometry (GC-MS)-based metabolomics was applied to assess the in vitro metabolic response of primary mouse hepatocytes (PMH, n = 10) to a heat stress stimulus, i.e., after 24 h exposure to 40.5 °C. Metabolomic profiling of both intracellular metabolites and volatile metabolites in the extracellular medium of PMH was performed.

RESULTS

Multivariate analysis showed alterations in levels of 22 intra- and 59 extracellular metabolites, unveiling the capability of the metabolic pattern to discriminate cells exposed to heat stress from cells incubated at normothermic conditions (37 °C). Hyperthermia caused a considerable loss of cell viability that was accompanied by significant alterations in the tricarboxylic acid cycle, amino acids metabolism, urea cycle, glutamate metabolism, pentose phosphate pathway, and in the volatile signature associated with the lipid peroxidation process.

CONCLUSION

These results provide novel insights into the mechanisms underlying hyperthermia-induced hepatocellular damage.

Drug-induced movement disorders

Many therapeutic and illicit drugs can cause movement disorders Antipsychotics and antiemetics are most commonly implicated

The time of onset of the movement disorder may be acute subacute or chronic The severity can range from mild to severe and life-threatening

Early recognition of a drug-induced movement disorder is essential to allow for prompt intervention This includes stopping the offending drug supportive care and sometimes other pharmacological treatment