Case
Our patient was a 49-year-old White man. He presented to the emergency department with ataxia and confusion following ingestion of an unknown amount of aspirin. On the day of admission, he was leaning towards his left when walking, and appeared confused while attending a community behavioural health programme. His past psychiatric history was significant for schizoaffective disorder, bipolar type; Tourette syndrome; multiple suicide attempts via overdose; and polysubstance dependence, including tobacco, cocaine, alcohol, synthetic marijuana (K2 and spice), marijuana and benzodiazepines. From staff at his community behavioural health programme, he was also known to take other patients' medications. He had no significant past medical history and lived in a group home. Upon arrival in the emergency room the patient was lethargic but arousable, and was oriented to date and time but not to place. He denied ingesting any other substances besides his prescribed medications that morning. All standard laboratories were within normal limits except for a CO2 of 19.2 mmol/L, indicating metabolic acidosis, an anion gap of 13 mEq/L and a blood salicylate level of 43 mg/dL. His lithium level was 0.84 mEq/L. Acetaminophen levels were <15.0 µg/mL. The urine toxicology screen was negative for all illicit substances tested. A computed tomography scan of his head without contrast revealed no acute intracranial haemorrhage or midline shift. An electrocardiogram showed normal sinus rhythm, and a QTc interval of 447 ms.
On questioning, the patient admitted to taking ‘3 Tylenol’ (acetaminophen, paracetamol) that morning because it made him ‘feel good’, despite having no acetaminophen in his system. He denied any suicidal ideation. He was admitted for further treatment of altered mental status because of salicylate toxicity.
Psychiatry was consulted for assessment and management of the patient's psychiatric medications for schizoaffective disorder and Tourette syndrome. In the community, he received lithium carbonate 300 mg three times a day, haloperidol 15 mg twice daily and benztropine 2 mg daily. He was not prescribed any other out-patient medications. His psychotropic agents were continued in the hospital.
On examination, he was cooperative and pleasant although still lethargic. He was oriented to date and time, but named another local hospital for location. On the Mini-Mental State Examination, he scored 19/30, losing points for location, recall of 0/3 items at 5 min, inability to perform serial 7's or spell ‘world’ backwards, inability to complete the third instruction out of a three-step series of commands or copy the intersecting pentagons. He again denied any suicidal ideation or desire to self-harm and stated that he took ‘3 Tylenol’ the morning of his admission and ‘7 Tylenol’ the previous day. When asked to elaborate, he answered, ‘It gives me a buzz’ and ‘makes me feel good’. When asked if he had ingested acetaminophen or aspirin, he responded, ‘It was Tylenol’. For the duration of his stay, he believed he took acetaminophen and not aspirin. He also stated he had received the tablets from another patient at his day programme. He did not exhibit any signs or symptoms of depression, mania or psychosis. By the following day, his symptoms, including delirium and elation, had dissipated. Both the patient and his family were educated about NPM/OTC medication misuse, including potential morbidity and mortality. He returned to his group home in a stable condition.
Prior medical records showed that the patient had been admitted 5 months earlier for short-term memory loss and confusion. At that time, his blood salicylate level was 59 mg/dL and CO2 was 18.3 mmol/L with an anion gap of 18 mEq/L. Again, the urine toxicology screen for illicit substances was negative, and acetaminophen levels were <15.0 µg/mL. The patient stated then too that he had taken several doses of acetaminophen because it made him ‘feel good’. He had denied any suicidal ideation, and insisted that he had taken the ‘Tylenol’ for a ‘buzz.’ Following 3 days of treatment, he was discharged in a stable condition.
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