Case 872 -- A 31 year old male with aggressive behavior and fever

Contributed by Christopher Suciu, MD and Kenichi Tamama, MD, PhD, FCAP


The patient is a 31 year old male with an unknown past medical history. The police initially found him naked, confused, and acting violently. He was taken to the emergency department, where his initial vitals and physical exam were significant for a temperature of 38.2oC, heart rate of 112 beats per minute, blood pressure of 156/108, diaphoresis, mydriasis, dried blood in his nares, skin pop marks on his arms, and no focal neurological deficits. Pertinent laboratory studies are included in Table 1.

The patient was given a cooling blanket to prevent the potential progression to hyperthermia, intravenous fluids (IVF's) for renal protection, and benzodiazepines to reduce agitation. He continued to violently thrash and rant incoherently even though he received multiple doses of benzodiazepines. He was subsequently sedated with propofol and intubated. The results for his urine and serum toxicology studies are listed in Table 2.

The UDS identified the benzodiazepines used to treat the patient, but was negative for routine drugs of abuse. Nonetheless, because of his history, symptoms, and laboratory results, clinicians were highly suspicious that the patient's toxicity was due to an unknown drug.

What kind of drug did the patient consume, and which test is needed?


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