Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: a case report

Abstract

BackgroundThe high prevalence of comorbid illicit drug use in persons with chronic psychotic illness represents a strong determinant of psychotic relapse and rehospitalization. Epidemiological studies indicate changing patterns of illicit drug use in Australia, which are concerning because of increased use of crystal methamphetamine, also known as “ice.” An important complication of habitual use of crystal methamphetamine is the development of a dose-dependent acute psychotic reaction. We report a case of an acute psychotic relapse in response to polydrug use most notable for multiple recent binges of crystal methamphetamine. Unlike previously described case reports, our patient’s acute psychosis was refractory to ultra-high doses of multiple antipsychotic medications. This presented safety challenges due to the risk of serious side effects with high-dose antipsychotic medications.Case presentationA 30-year-old white man with a past history of schizoaffective disorder was brought to our emergency department by the police in a state of extreme agitation, combativeness, and paranoia after use of cannabis and crystal methamphetamine. Despite existing compliance with zuclopenthixol decanoate depot medication, he required multiple emergency injections of zuclopenthixol acetate, and regular high-dose droperidol, chlorpromazine, and lorazepam. However, he remained severely agitated and psychotic with continuous threats of harm to others. A test of antipsychotic drug metabolism by cytochrome P450 enzymes did not reveal a pharmacogenetic cause for the poor therapeutic efficacy of antipsychotic medications. His psychosis did not appear to be modified by psychoactive medications but was instead self-limited to the presence of endogenous methamphetamine within his system. He fully recovered 96 to 120 hours post-presentation and was discharged home with out-patient clinic follow-up.ConclusionsThe current case highlights the challenging nature of a severe psychotic relapse precipitated by illicit substances that is resistant to medical management. High doses of multiple antipsychotic medications may be required to manage dangerous behaviors associated with these acute psychotic relapses. These patients require close monitoring for adverse effects with adjustment of dosing to ensure the optimal balance of risk versus benefit while the patient is acutely psychotic. The results are of relevance for the management of psychiatric emergencies in emergency departments and acute mental health settings.

Guidelines and treatment for illicit drug related presentations in emergency departments: A scoping review

“…The most recent guidelines from Australia, [16][17][18] the UK 19,20 and the US [21][22][23][24][25][26] (Table 1) and eleven original studies [27][28][29][30][31][32][33][34][35][36][37] and a transcript of evidence 15 (Table 2) were included in this review.…”

Stylistic features of case reports as a genre of medical discourse

“…Hence, MCRs are notable for their use of active sentences in the simple past tense (309 cases) [ 3 , 5 – 18 ]: “We maintained anesthesia with inhaled desflurane at 5% and intravenously administered remifentanil at 0.2 μg/kg/min in a fraction of inspired oxygen of 0.45 (…) At that moment, we administered 20 mg ephedrine, 300 μg phenylephrine, and 0.03 μg/kg/min norepinephrine to maintain adequate blood pressure (…) We did not detect any problems with his respiratory parameters (…) His systolic blood pressure remained at 40 mmHg for 10 min; we performed chest compressions to maintain his blood pressure” [ 5 ]; “We did not find cases with such an evolution in the literature, but we found some cases of spontaneous expulsion of ileal lipoma per rectum” [ 6 ]; “We found electrogram amplitude to be normal throughout the right ventricle (…) In this case we used cryoablation to avoid the pain associated with radiofrequency delivery” [ 7 ]; “An extraoral examination revealed a diffuse swelling of her left nasal alar base without tenderness” [ 8 ]; “Two patients with EHPVO presented with micrognathia, restricted mouth openings, and facial asymmetry” [ 9 ]; “Brain magnetic resonance imaging (MRI) did not identify any abnormalities, but an ophthalmic examination revealed vertical supranuclear gaze palsy (VSGP), and analysis of peripheral blood and bone marrow biopsies identified vacuolated histiocytes” [ 10 ]; “…we considered electroconvulsive therapy; clinicians may opt for electroconvulsive therapy at an earlier stage in similar psychiatric emergencies (…) We hypothesized that our patient’s poor clinical response was from a genetic polymorphism in the drug-metabolizing activity of cytochrome P450 enzymes” [ 11 ].…”

“…The use of the present simple tense is also comparatively infrequent and it is generally used only in the opening section of MCRs (23 cases in the analyzed discourse): “We report a rare case of a CVC tip malpositioned in the right internal mammary artery (IMA)” [ 13 ]; “ We describe the case of a 30-year-old man from the north of Morocco with no medical or surgical history and no family history of rectal disease” [ 6 ]; “ We describe a case in which RVOT ectopy was complicated by ventricular fibrillation (VF) arrest despite the absence of any of the recognized risk factor for cardiac arrest and despite an apparently positive response to pharmacological therapy” [ 7 ]; “Here, we present two cases where difficult intubation was anticipated, and in which, despite trying various devices to visualize and secure the airway, only the use of a Macintosh blade proved successful” [ 9 ]; “ We report a case of an acute psychotic relapse in response to polydrug use most notable for multiple recent binges of crystal methamphetamine” [ 11 ].…”

CARE guidelines for case reports: explanation and elaboration document. Translation into Russian

“…• Вызванный полинаркоманией рецидив шизоаффективного расстройства, рефрактерного к большим дозам антипсихотиков: описание случая [45]. «Была начата экстренная седация зипрасидоном, лоразепамом, дроперидолом и зуклопентиксола ацетатом (табл.…”