5 Interesting Medication Case Reports - Part 6

JANUARY 05, 2018
This article is part 6 of a 6-part series on interesting and unusual medication-related case reports. For part 5 click here

Case reports are defined as the scientific documentation of an individual patient. These reports are often written to document an unusual clinical presentation, treatment approach, adverse effect, or response to treatment. Most experts see case reports as the first line of evidence in health care, which can sometimes lead to future higher-level studies.
Case reports can be a great learning opportunity for both pharmacists and pharmacy students to understand a case progression and the unconventional response and effects of medications.
This article highlights 5 published case reports that document some of the most unusual medical cases published in medical literature.
1. Effects associated with lifetime intake of 40,000 ecstasy tablets1
MDMA (nicknamed ecstasy/molly) is a synthetic drug that alters mood and perception. An estimated 18.9 million Americans 12 or older have tried ecstasy at least once, representing nearly 7% of the US population in that age group, according to the 2016 National Survey on Drug Use and Health. In 2006, a group of clinicians published a case report detailing the neurological and pathological effects from ingesting the largest amount of ecstasy that has ever been reported in medical literature.
The article documents the history of a 37 year-old man who used ecstasy between age 21 and 30. For the first 2 years, he reported taking 5 tablets every weekend, escalating to an average daily use of 3.5 tablets for the next 3 years and then further escalating to an average of 25 tablets daily over the next 4 years. An estimate of lifetime consumption revealed a total intake of more than 40,000 tablets. At the time of admission, he reported current cannabis consumption along with polydrug misuse (eg, amphetamines, benzodiazepines, cocaine, heroin, and LSD). He said that he stopped ecstasy use after 3 episodes of collapsing at parties.
For a few months after stopping ecstasy, the patient felt as if he was still under the influence of the drug and suffered episodes of depression, hallucinations, limited attention and concentration, muscle rigidity, paranoid ideation, recurrent anxiety, sever panic attacks, and “tunnel vision." A structural MRI brain scan revealed no focal cerebral lesions. He was prescribed olanzapine 10 mg and admitted to a brain injury unit, where he demonstrated some improvement in memory skills.
2. Laugh-induced seizures2
In 2013, clinicians published a case report detailing the first documented case of laugh-induced seizure. The case involved a 43-year-old obese, Caucasian man with a past medical history of bipolar disorder, chronic headaches, and insomnia. His medication list included valproic acid and topiramate. In the month prior to admission, he had several mild seizures which were induced by laughter when he was watching comedy shows on television. Each episode lasted about 5 to 10 seconds, with an average of 5 seizures a day, depending on the length and intensity of the comedy shows. He had no family history of seizure disorder.
A physical exam was performed, which reviewed normal vital signs. Cardiovascular, neurological, and respiratory examinations were all unremarkable. His electrolyte glucose levels were within the normal range. An MRI scan revealed an arachnoid cyst in the anterior right middle cranial fossa. However, an EEG did not identify this as a causative factor for the seizures. Drug-induced seizure was also ruled out.
The patient was subsequently placed on carbamazepine, which controlled his seizures for the next year of follow up. The authors were unable to explain the mechanism between laughter and invoking seizure and said that further study is required to establish the standard treatment guidelines for this condition.
3. Sexual intercourse as treatment for intractable hiccups3
Hiccups are caused by involuntary contractions of the diaphragm, followed by closure of the vocal cords, resulting in a “hic” sound. Common causes of hiccups include coughing, swallowing air excessively, rapid eating or laughing, gastrointestinal disorders, nervous system disorders, and sometimes drug therapy. In part 2 of this series we discussed several case reports involved drug-induced hiccups.
In 2000, 2 clinicians published a case report where sexual intercourse successfully treated intractable hiccups. The case begins with a 40-year-old man who suffered from low back pain, which was not alleviated with nonsteroidal anti-inflammatory drug therapy. The patient was subsequently treated by a neurologist, who gave him a him an injection of a 5 mL mixture of 1% lidocaine, betamethasone sodium phosphate, and betamethasone acetate. Although the patient experienced immediate pain relief, 6 hours later he developed intractable hiccups.
To resolve the hiccups, the patient tried and failed metoclopramide, chlorpromazine, and several folk remedies. On the fourth day of continuous hiccupping, he had sexual intercourse with his wife. The hiccups continued up until the moment of ejaculation, when they suddenly and completely ceased. They did not recur over a follow-up period of 12 months.
The authors hypothesized that resolution of the hiccups following ejaculation could possibly be the result of the sympathetic stimulus stemming from ejaculation, which might have terminated the reflex arc that caused the hiccups. The authors explain that this is the first published case report in medical literature showing that sexual intercourse can terminate intractable hiccups.
4. Covert administration of medications to control an agitated patient4
In 2006, clinicians from the University of California published a case report involving the covert administration of medication to a patient in the emergency department (ED), as well as the ethical, legal, and therapeutic issues surrounding this type of case.
The case starts with a 32-year-old man with bipolar affective disorder discontinuing his medications 6 months before presenting to the ED with homicidal and suicidal ideation. He walked into the ED, after being convinced by his sister but would not let anyone touch him, even for vital signs, and refused a psychiatrist visit. His family reported previous violent confrontations with ED staff and that he had not slept for at least 1 week.
During the visit, the ED physician consulted with the sister, who approved a plan to have the nurse inject both haloperidol and lorazepam into a sealed orange juice container and give it to the patient. The patient accepted the drink and 30 to 45 minutes later was calm and cooperative, was admitted to the psychiatry service, and discharged home 3 days later.
Near the end of the patient’s stay in the ED some of the hospital staff expressed reservations about how the patient was administered the medication, resulting in the case being reviewed by risk management and an independent 6-member panel. Both review bodies disapproved of the covert administration of medication, stating that it was “probably illegal.” Additionally, 4 of the 6 members on the panel also called the physician’s actions unethical. The authors detailed arguments both for and against the ED physician’s actions and further explore the topic of consent. They explained that there is no specific guidance on the practice of covert medication in the ED setting and that no case reports or studies on the topic have ever previously been published.
5. Ocular injury due to cigarette liquid misuse5
Electronic cigarettes (ECs) are handheld devices that attempt to mimic the feeling of tobacco smoke by heating a liquid into an aerosol for inhalation. Since their introduction in 2006, ECs have risen in popularity as a potentially safer alternative to traditional cigarettes.
This 2016 case report documents the story of a woman in her 50s who presented to an acute eye service with unilateral eye irritation. She had recently been prescribed chloramphenicol eye drops for a suspected bacterial conjunctivitis. The woman stored the prescription eye drops next to her EC refill liquid in the bathroom and mistakenly administered the EC fluid to her eye, resulting in instant ocular pain, redness, and blurred vision. Upon admission, there was superficial punctate straining on the cornea but otherwise no epithelial defect. There was no long-term damaged noted for vision loss or pain.
Further investigation showed a similarity between the antibiotic eye drop and EC liquid bottles. The authors said that case shows the importance of storing EC liquid away from other medical bottles to minimize potential confusion. They also recommended that manufacturers of EC fluid consider carrying additional guidance on seeking medical attention if the fluid comes into contact with the eyes.

1. Kouimtsidis C, Schifano F, Sharp T, Ford L, Robinson J, Magee C. Neurological and psychopathological sequelae associated with a lifetime intake of 40,000 ecstasy tablets. Psychosomatics. 2006;47(1):86-7.
2. Mainali NR, Jalota L, Aryal MR, Schmidt TR, Badal M, Alweis R. Laugh-induced seizure: a case report. J Med Case Rep. 2013;13;7:123. doi: 10.1186/1752-1947-7-123.
3. Peleg R, Peleg A. Case report: sexual intercourse as potential treatment for intractable hiccups. Can Fam Physician. 2000;46:1631–2.
4. Lewin MR, Montauk L, Shalit M, Nobay F. An unusual case of subterfuge in the emergency department: covert administration of antipsychotic and anxiolytic medications to control an agitated patient. Ann Emerg Med. 2006;47(1):75-8.
5. Jamison A, Lockington D. Ocular Chemical Injury Secondary to Electronic Cigarette Liquid Misuse. JAMA Ophthalmol. 2016;134(12):1443. doi:10.1001/jamaophthalmol.2016.3651.

Timothy O'Shea, PharmD
Timothy O'Shea, PharmD
Timothy O'Shea, PharmD, is a Clinical Pharmacist working at a large health insurance plan on the east coast. Additionally he works per diem at a retail pharmacy chain. He graduated from MCPHS University - Boston in 2015 and subsequently completed a PGY-1 Managed Care Pharmacy Residency. His professional interests include pharmacy legislation and managed care pharmacy. He can be followed on Twitter at @toshea125.
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