A 26-Year-Old Woman With Confusion and Hyperthermia

Caroline Tschibelu, MD

Disclosures

February 24, 2017

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 26-year-old woman presents to the emergency department (ED) with confusion, agitation, sweating, and abnormal involuntary eye movement (diaphoresis and ocular clonus). The symptoms started the previous week; they were mild at first, and the patient attributed them to a heat wave in the city all week long.

The patient felt worse as the week went on and decided to come to the ED because she was not feeling better that morning. She started sweating profusely in the middle of the night, felt her leg muscles become stiff, and was increasingly nauseous. Her fiancé insisted she go to the ED as early as possible because she seemed agitated and confused, pacing around the apartment instead of taking a shower.

The patient's history is reviewed with her fiancé. She has a history of depression, for which she takes fluoxetine; her dose was increased by her psychiatrist 1 month ago. For migraines, she takes sumatriptan and ondansetron. Because her headaches have recently worsened, her neurologist started her on tramadol. She also has had a cough, for which she self-medicated with dextromethorphan. The remainder of her medical history is noncontributory.

She does not smoke, denies drugs and alcohol use, and has no allergies or family history of other significant illness.

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