Case and Questions and answers. Case created from multiple case reports.

Case: A 22 year old female is brought in to the emergency department by ambulance following her collapse at an electronic dance music festival. A friend accompanying her states that she had taken at least 3 hits of Molly, otherwise known as MDMA, a street drug that in its pure state is a phenethylamine. Vitals are notable for a body temperature of 42.5C, heart rate of 132 bpm, and a respiratory rate of 23. Her friend reports that she had a seizure before being brought by ambulance, and the seizures continued en route to the ED. Physical examination at presentation showed bilateral mydriasis, myoclonus, a systolic murmur, and a thrill over the femoral arteries. The patient's arterial blood pressure was 125/45 mm Hg. She is diaphoretic and currently non-responsive. Her labs, EKG, and histopathology are shown below. 1) Treatment is initiated and includes cooling measures and administration of a benzodiazepine. Choose the benzodiazepine with the shortest half life, along with the correct antidote in case of benzodiazepine overdose.

a) alprazolam/naloxone b) lorazepam/cyproheptadine c) midazolam/flumazenil d) diazepam/desipramine e) alprazolam/flumazenil f) midazolam/dantrolene g) lorazepam/naloxone h) alprazolam/dantrolene

2)

The patients EKG shows signs consistent with hyperkalemia. These will include: a. Inverted U wave b. ST elevation c. ST depression d. Widened QRS e. Peaked T wave f. Q waves g. Flattened P wave h. Shortened QT i. T wave inversion j. B, F, & I k. A, C, & H l. E, D, & G m. A, C, & E

3)

Hyperkalemia is dangerous because it can induce a heart arrhythmia, especially in the setting of metabolic acidosis such as in our patient. Treatment was initiated to lower the patients serum potassium. In addition to sodium bicarbonate, which of the following combinations will be most appropriate for lowering the patients serum potassium level? a) calcium gluconate, dantrolene, amiloride b) insulin, metoprolol, amiloride c) glucose, calcium gluconate, insulin d) glucose, spironolactone, dantrolene e) calcium gluconate, insulin, metoprolol

4) Unfortunately, the patients heart rhythm becomes asystolic. Resuscitation efforts fail and the patient is pronounced dead at 5:00am. At autopsy the following pathology specimens are obtained. In Figure 2 we see an H&E stain of the patients myocardium. Based on the presence of macrophages in the slide shown, how long ago was the patients MI that caused these changes? a. 30 minutes to 4 hours b. 4 12 hours c. 12 24 hours d. 3 10 days e. 2 8 weeks

5)

Histopathology is also performed on renal tissue, an example of which is shown at left in Figure 3. What pathological process could explain the patients renal biopsy result, positive dipstick for blood in the urine, elevated creatine kinase, and hyperkalemia? a. Hyperbilirubinemia due to liver failure b. Acute tubular necrosis due to rhabdomyolysis c. Intravascular hemolysis