is an atypical antipsychotic that affects the dopaminergic pathway and is commonly used in the treatment of schizophrenia and bipolar disorder. Common side effects include extrapyramidal syndrome, akathisia, hyperprolactinemia, weight gain, and transaminitis. Rare adverse effects include hypothermia, bradycardia, and hemodynamic instability, while neutropenia is even more rare. CASE PRESENTATION: A 64-year-old woman with history of schizophrenia was brought in from jail for bilateral lower extremity edema and hypothermia unrelated to environmental exposure. On arrival, she was agitated, hypotensive (MAP <60), bradycardic (HR in 50s), and hypothermic with a rectal temperature of 90.4 F. Due to the patient's psychotic state, no history could be elicited. Initial differential diagnoses included myxedema coma and sepsis. Fluid bolus, antibiotics, intravenous levothyroxine and hydrocortisone were immediately administered. Laboratory findings were significant for neutropenia with an absolute neutrophil count of 984, which was previously normal three weeks earlier. Peripheral smear demonstrated few large granular lymphocytes, which are normal variants. Thyroid studies showed a normal free T4 and mildly elevated TSH with a value of 6.45 mcIU/mL (0.34-5.60 mcIU/ml), consistent with subclinical hypothyroidism. Additional findings included a normal lactate, clear urinalysis, unremarkable chest x-ray, and pan-CT non-revealing for an infectious source. Patient did have bilateral lower extremity erythema and edema concerning for bilateral lower extremity cellulitis, but this was not significant enough to account for her severe hypothermia, bradycardia, and hemodynamic instability. On further investigation, the only medication the patient was taking at the time of presentation was olanzapine, a court-ordered medication for her psychotic symptoms, which was started thirteen days prior to symptoms. During her hospital stay, olanzapine was stopped and switched to aripiprazole (Abilify), which was tolerated well by the patient in the past. Additionally, with active warming and supportive care with fluids and antibiotics, the patient's clinical condition improved. Neutropenia resolved five days after olanzapine was discontinued, and all culture data returned without any sign of infection. DISCUSSION: This case illustrates how rare adverse reactions from an antipsychotic medication can confound the clinical picture and mimic another diagnosis, specifically myxedema coma and sepsis. There have been less than a hundred reported cases of antipsychotic-related hypothermia and only two reported cases of olanzapine-related neutropenia in the literature. CONCLUSIONS: Awareness of these rare adverse reactions, alongside a thorough investigation and open-minded differential were critical in deciphering this intriguing case.

No abstract

Hyperleukocytosis is defined as WBC >100,000/mL and seen in up to 20% of acute myelogenous leukemia (AML).1 However, clinical signs of leukostasis and/or leukemic infiltration develop in 30-40% patients even at lower WBC counts with acute respiratory failure being a major cause for early mortality.3,5 CASE PRESENTATION: An 86-year-old woman, recently diagnosed with AML three-weeks ago not yet started on chemotherapy, and deep venous thrombosis (DVT) on anticoagulation, was admitted with dyspnea. On exam, she had diminished breath sounds, crackles in the right base, and right lower extremity edema. Initial leukocyte count was 25,000/mL with monocytic predominance. She was tachycardic and tachypneic but breathing comfortably on room air. A venous blood gas (VBG) showed pH 7.41, pCO2 38 mmHg and lactate 2.5 mmol/L. Chest radiograph showed bilateral patchy opacities. CT Angiogram was unremarkable for pulmonary embolism (PE). Duplex US was unrevealing for DVT. At 20-hours after admission, she had progressively altered mentation, increased work of breathing at 30-40 breaths/minute and hypoxia requiring supplemental oxygen. VBG showed pH 7.36, pCO2 37 mmHg and lactate 6.1 mmol/L. Leukocyte count increased to 55,000/mL. At 28-hours, respiratory support was escalated to BiPAP and VBG showed pH 7.10, pCO2 47 mmHg, and lactate of 9.7 mmol/L. Leukocyte count increased to 72,000/mL. While planning for emergent leukapheresis, the patient suffered a respiratory arrest and died despite full resuscitative efforts. Autopsy examination showed extensive infiltration by leukemic monocytic cells in the lungs, heart and brain. Notably, the lungs had a pale white-pink pallor and intraluminal material showed congestion in larger pulmonary vessels and infiltration within the alveolar by atypical hematolymphoid cells.

No abstract