November 2010

Fig.1

Fig.2

Fig.3

 

 


History: A 30 year old Caucasian male was brought in by ambulance after being found unconscious in his hotel room.  A suicide note was found along side an empty bottle of Seroquel and  partially empty bottles of Depakote and lithium. When revived, the patient later claimed to have taken seventy-five 300mg pills of Seroquel with a bottle of vodka.   Initial vitals showed a heart rate of 120 BPM, blood pressure of 144/76 and oxygen saturation of 99% on 15L O2.  He was intubated in the ED for airway protection.   He was noted to have multiple large bullae and erythematous patches on his distal extremities and Dermatology was consulted.

Past Medical History: Schizophrenia, Bipolar disorder, hypertension, ADHD

Medications:
Outpatient: Seroquel, Depakote, lithium
Inpatient: cefepime, vancomycin, nicotine patch, ibuprofen

Social History: Marital status – in the process of getting a divorce.
Smokes one pack per day. History of alcohol dependence.  History of drug use including methamphetamines, crack cocaine, heroin, LSC and marijuana.

 

Physical Exam: Unconscious, intubated. Skin showed non-inflammatory bullae on medial knees bilaterally (Fig.1) and on right dorsal hand (Fig.2).  Erythematous macules were present caudal to the anterior superior iliac spines bilaterally, on the right first toe, and on the left dorsal foot (Fig3).

Laboratory:
CMP and CBC, magnesium, phosphorus: normal
Valproic acid: 1 (low), Salicylate: <0.5 (normal),
Lithium: <0.2 (low), Ethanol: <10 (normal)
Acetaminophen: 2.3 (normal)
Urine drug screen: positive for opiates
Hepatitis and HIV: negative
Blood, urine and respiratory cultures: no growth

Imaging: Head, C-spine CT: No acute injuries.

 

 Click here for the diagnosis