Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

American Journal of Emergency Medicine 34 (2016) 757.e3-757.e5

When a seizure is not a real seizure!

Abstract

We report here 2 cases of methadone induced Torsades de pointes with a clinical presentation mimicking convulsive seizures in a sub- stance abuser These cases highlight the importance of being aware of methadone-induced Torsades de Pointes and the occasional Atypical clinical presentations of this condition.

“Torsades de Pointes” (Tdp) is a Polymorphic ventricular tachycardia caused by a congenital or acquired long QT syndrome. Methadone asso- ciated prolonged corrected QT (QTc) can be a surrogate marker for a po- tentially fatal arrhythmia [1-3]. As a result, a black box warning for methadone was issued in 2006 by the US Food and Drug Administration, alerting practitioners to the increased risk of TdP. drug-induced TdP is most likely to occur when a 25% increase in the baseline QT interval is noted or if the QTc is N 500 milliseconds [4-6].

The most frequent clinical manifestations of TdP are palpitations, dizziness and syncope. Torsades de Pointes is usually self-terminating and resolves spontaneously within seconds, but could deteriorate into a fatal ventricular tachycardia and death. These patients may exhibit seizure-like signs, likely from Brain hypoxia during Tdp [7,8].

A 60-year-old woman presented to the emergency department with a 6-month history of frequent convulsive episodes. These episodes were occurring up to 3 times per week and described as sudden jerky move- ment of the patient’s arms while she remained unresponsive for ap- proximately one minute. The Patient reported urinary incontinence during some episodes. Afterwards, she was fatigued and had no recol- lection of what had just occurred. She denied any prodromal symptoms. The last episode was the day before coming to hospital. According to the patient she was working when she started to feel dizzy, which was ac- companied by visual changes and vertigo. Patent states she was feeling sick and was able to sit in a chair, then she doesn’t recall what happened but woke up on the floor, unwitnessed. She had history of untreated Hepatitis C and heroin abuse. She was on 120 mg daily of methadone for last 6 years.

Her vital signs, physical examination, metabolic profile and comput- ed tomographic scan of the head were normal. Electrocardiography revealed significant prolongation of QTc (521 milliseconds) and generalized ST, T changes with multiple extra systole (R on T wave). Prior ECG was normal (Fig. 1). Echocardiography reveled global hypokinesia with moderate reduced ejection fraction (35%-40%). On the first day of admission the patient coded in the coronary care unit and sustain polymorphic ventricular tachycardia was seen and it was cardioverted by DC shock. Methadone was discontinued and it was re- placed with morphine 30 mg oral every 8 hour. Cardiac catheterization did not show any coronary artery disease, She was given a life vest and

morphine dose was tapered. During the 6-month follow up, the patient did not experience any episode of syncope and ECG normalized.

A 48 year-old-man was brought in by ambulance (EMS) after being found unresponsive in the street. As per EMS records the patient had collapsed in the street, witnessed by bystanders. He was found with uri- nary incontinence and with shallow breathing. He was intubated at the scene. An ECG was obtained which showed a wide complex rhythm, and third-degree AV block. He then had an episode of non sustained ventric- ular tachycardia, and several minutes later became hypotensive and rhythm deteriorated into a polymorphic sustained ventricular tachycar- dia, for which he was electrically cardioverted. The rhythm then con- verted to sinus tachycardia with a heart rate of 154 bpm. The heart rate progressively decreased to 140 bpm allowing us to see the signifi- cant QTc prolongation (568 milliseconds) (Fig. 2).

Our patient had history of poly substance abuse and was on Methadone 120 mg daily for past 5 years. He had a history of witnessed seizures for the past four years. Family described seizure as rapid breathing associated with bilateral dystonic arm posturing, whole body myoclonic jerks and noisy breathing before he became completely unresponsive, flaccid and became apneic for 54 seconds. He then resumed breathing and gradually regained consciousness. He had been on anticonvulsive medication without adequate re- sponse for last 4 years. Brain computed tomographic scan and elec- troencephalogram on previous and recent admission were normal. After reducing the methadone dose to 40 mg Po daily and replacing electrolytes the ECG became normal. Echocardiography showed nor- mal ejection fraction.

Physicians should be aware of QT prolongation secondary to metha- done therapy and the Drug interactions that may potentiate toxicity from methadone. Torsade de pointes should be included in the differen- tial diagnosis when evaluating patients on methadone, especially those complaining of syncope or seizures. Associated risk factors for QT pro- longation in these patients include concomitant medications or drugs that prolong the QT, HIV infection, hypokalemia, Female gender, liver cirrhosis, renal failure, and heart disease should all be considered.

Soheila Talebi, MD

New York Medical College, Metropolitan Hospital, Medicine Department

New York, NY

Farzaneh Ghobadi, MD New York Medical College, Metropolitan Hospital Emergency Department, New York, NY

Sameer Chaudhari, MD

Newark Beth Israel Medical Center, cardiology department, New York, NY

0735-6757/(C) 2015

757.e4 S. Talebi et al. / American Journal of Emergency Medicine 34 (2016) 757.e3-757.e5

Fig. 1. A, Baseline ECG: Normal sinus rhythm, Normal QTc interval: 396 milliseconds. B, ECG upon admission: Normal sinus rhythm with Generalized ST, T, changes with prolonged QTc: 521 milliseconds. C, ECG upon admission: normal sinus rhythm, Bigeminy premature ventricular complex (R on T wave).

Fig. 2. A, ECG upon admission: Normal sinus rhythm with wide complex QRS and prolonged QTc: 474 milliseconds. B, Paroxysmal supraventricular tachycardia . C, ECG after control PSVT: Normal sinus rhythm with prolonged QTc: 568 milliseconds.

S. Talebi et al. / American Journal of Emergency Medicine 34 (2016) 757.e3-757.e5 757.e5

Ely Gracia, MD Ola Olatunde, MD

New York Medical College, Metropolitan Hospital, Medicine Department

New York, NY

Gerald Pekler, MD Ferdinand Visco MD

New York Medical College, Metropolitan Hospital, Cardiology Department

New York, NY

Getaw Worku Hassen, MD, PHD

New York Medical College, Metropolitan Hospital, Emergency Department

New York, NY Corresponding author at: New York Medical College, Metropolitan Hospital, Emergency Department, 1901 1st Avenue

New York, NY, 10029. Tel.: +1 212 423 6262

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.07.077

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