SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Quetiapine is a second-generation antipsychotic (SGA) commonly used for a wide range of psychotic and mood disorders. Common metabolic side effects include weight gain, hyperglycemia, dyslipidemia, and diabetes mellitus. CASE PRESENTATION: A 69-year-old black lady with schizophrenia and dementia was admitted for unresponsiveness noted a few hours before arrival. She was in her normal state of health until the morning of admission. She was started on quetiapine 150mg at bedtime, 2 weeks ago. Vital signs showed: T-88F, HR-110bpm, RR-22, BP-95/60mm of Hg, SpO2-96% on ambient air. Physical showed an unresponsive patient with a GCS<8. She was intubated for airway protection. Fingerstick blood glucose (BG) was 35 mg/dL. Serum studies showed WBC count-3,800 cells/mm3, BG-46 mg/dL and HbA1c-4.3%. She was treated for presumed sepsis with broad-spectrum antibiotic coverage, D5NS, and received external rewarming measures (ERMs). The rest of the workup, including blood and urine cultures, was negative and antibiotics were discontinued. Imaging studies did not reveal an etiology for her acute deterioration. The patient improved clinically and was extubated after 24hrs. D5NS, ERM was discontinued and her home dose of quetiapine was resumed. The next morning, she was lethargic and noted to have rebound hypothermia and hypoglycemia both on fingerstick BG and BMP. An extensive workup for hypoglycemia that included insulinoma, factious hypoglycemia and adrenal insufficiency returned negative. Hypoglycemia and hypothermia resolved only after dose reduction of quetiapine to 25mg twice daily. DISCUSSION: SGAs have extensive side effect profile some of which are obscure. SGA-induced hypoglycemia and hypothermia are rare and only a few cases of isolated hypoglycemia or hypothermia from different members SGAs are reported. Although pathophysiology is unclear, SGA-induced hypothermia is thought to be mediated by increased affinity for 5-HT2 receptors and SGA-induced hypoglycemia is thought to be caused by increase in insulin secretion in nondiabetic patients. Symptoms of hypoglycemia can be mistaken for sedative effects from these medications. Also, a combination of hypothermia and hypoglycemia can mimic other presentations such as sepsis in this case. So, a strong clinical suspicion must be maintained for diagnosis. Symptomatic treatment along with switching to a different SGA or dose reduction of the current SGA can help in management. This case is unique with simultaneous findings of hypothermia and symptomatic hypoglycemia from quetiapine which was not reported in literature to our knowledge. CONCLUSIONS: With the increasing use of SGAs, it is important to be aware of potentially fatal and rare side effects of hypoglycemia and hypothermia. A knowledge of this can help in early recognition and avoid extensive diagnostic studies and inappropriate management strategies. Reference #1: Suzuki Y, Watanabe J, Fukui N, Ozdemir V, Someya T. Hypoglycaemia induced by second generation antipsychotic agents in schizophrenic non-diabetic patients. BMJ. 2009;338:a1792. Published 2009 May 26. doi:10.1136/bmj.a1792 Reference #2: Omi T, Riku K, Fukumoto M, et al. Paliperidone Induced Hypoglycemia by Increasing Insulin Secretion. Case Rep Psychiatry. 2016;2016:1805414. doi:10.1155/2016/1805414 Reference #3: Kreuzer P, Landgrebe M, Wittmann M, et al. Hypothermia associated with antipsychotic drug use: a clinical case series and review of current literature. J Clin Pharmacol. 2012;52(7):1090-1097. doi:10.1177/0091270011409233 DISCLOSURES: No relevant relationships by Mouna Gunda, source=Web Response No relevant relationships by Jewell Halanych, source=Web Response No relevant relationships by Prudhvi Regula, source=Web Response No relevant relationships by BINITA VADHAR, source=Web Response
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