A 65-year old man is brought to the ED for hallucinations. He is unable to provide a history but he is hyperthermic, tachycardic, and his extremities appear spastic and rigid. You see the following on physical exam of his abdomen. What's the diagnosis? (scroll down for answer)

Answer: Baclofen withdrawal

• Intrathecal baclofen pumps are used for the treatment of intractable spasticity for patients who have cerebral palsy, spinal cord and/or cerebral injury

• Reasons for withdrawal include pump malfunction, under-filled/empty pump, recent dose reduction, catheter issue

• May present as hallucinations, rigidity, hyperthermia, tachycardia, seizures about 24-48 hours after last dose

• Check labs including a CK to assess for rhabdomyolysis as well as renal or hepatic failure

• Treatment includes benzodiazepines, external cooling and potential intubation and propofol; oral baclofen typically cannot achieve adequate CNS penetration

• Differential diagnosis includes sepsis, serotonin syndrome, heat stroke, neuroleptic malignant syndrome, excited delirium / drug use, withdrawal syndromes

• Typically needs ICU admission, neurosurgery consult for pump interrogation and management if there is a true pump or catheter malfunction

• To review what happens at the opposite end of the spectrum, review this EM Daily post for the warning signs of baclofen toxicity!

References

• Rao R.B. (2015). Special Considerations. In Hoffman R.S., Howland M, Lewin N.A., Nelson L.S., Goldfrank L.R. (Eds), Goldfrank’s Toxicologic Emergencies, 10e.
• Swaminathan, Anand. (2016), Baclofen Withdrawal. REBEL EM. Accessed September 20, 2017. Available at http://rebelem.com/baclofen-withdrawal/.