A 13-year-old girl with sickle cell disease who had been treated with prescribed morphine sulfate (which had been discontinued several months prior due to concerns of misuse) was transported to the emergency department (ED) because her mother found her unresponsive at home with sonorous respirations. The patient's mother informed the emergency medical services providers that the patient had received an infusion in the hematology clinic the day prior and had not been feeling well. On the morning of ED presentation, the patient ingested a 25-mg diphenhydramine tablet and then took a nap around 10:00 AM. When the patient's mother could not wake her at approximately 3:00 PM, she called 911. Upon arrival, emergency medical services described agonal respirations and miosis. The patient was endotracheally intubated in the prehospital setting for airway protection and hypoxemia. After intraosseous (IO) access was established, the patient was transported to a pediatric ED.
In the ED, the patient was unresponsive with a Glasgow Coma Scale (GCS) score of 3T (severe). The patient's vital signs included the following: blood pressure, 95/57 mmHg; pulse, 161 beats per minute; temperature, 38.1 ˚C (100.5 ˚F); pulse oximetry, 100% on 100% oxygen via bag-valve-mask ventilation of her endotracheal tube. Physical examination was notable for diaphoresis and 1 to 2 mm sluggish pupils. Due to difficulty with bag-valve ventilation, 0.8 mg naloxone was administered via intraosseous infusion. The patient immediately awoke, promptly self-extubated, and vomited twice while maintaining her airway. Her complete blood count demonstrated a hemoglobin of 10.5 g/dL (reference range, 11.1-15.7 g/dL) and a platelet count of 142 thousand/mm3 (reference range, 140-350 thousand/mm3). Coagulation study results included the following: Pro Time, 25.4 seconds (reference range, 12.0-14.6 seconds); D-dimer, greater than 20.00 µg/mL (reference range, <0.50 µg/mL); fibrinogen, 129 mg/dL (reference range, 180-500 mg/dL). Liver enzyme results included aspartate aminotransferase of 221 U/L (reference range, <41 U/L) and alanine aminotransferase of 132 U/L (reference range, <56 U/L). Serum chemistries included a creatinine result of 1.58 mg/dL (reference range, 0.57-0.80 mg/dL). The patient's serum lactate measured 8.9 mmol/L (reference range, 0.5-2.1 mmol/L). A preliminary urine drug screen of abuse immunoassay detected opiates. Serum acetaminophen, salicylate, and ethanol concentrations measured 2 µg/mL, <2 mg/dL, and undetectable, respectively. A chest radiography revealed hypoinflated lungs with no acute cardiopulmonary process and stable cardiomegaly. A head computed tomography (CT) scan showed no acute intracranial abnormality. In the ED, the patient became somnolent again, so a subsequent dose of intravenous (IV) naloxone (0.8 mg) was administered. She became more arousable, vomited once more, but continued to maintain her airway with a GCS of 11 (moderate). The patient scored 10 (definite) on the Naranjo Adverse Drug Reaction Probability Scale.
The patient was admitted to the pediatric intensive care unit. On hospital days (HD) 1 and 2, she demonstrated intermittent periods of somnolence requiring IV naloxone administration (0.8 mg) with subsequent vomiting. She received IV fluids, albumin, ceftriaxone, and vancomycin for concerns of sepsis. In addition, the patient received an exchange transfusion.
On HD 2, the patient was easily arousable, breathing comfortably with normal pupillary examination. A serum expanded toxicology screen (liquid chromatography/mass spectroscopy) obtained from blood on admission detected codeine, hydromorphone, and morphine. In the patient's urine, each of these were detected as well, with concentrations of 170 ng/mL, 551 ng/mL, and >20,000 ng/mL, respectively. Notable chemistries included a serum creatinine of 3.28 mg/dL (reference range, 0.57-0.80 mg/dL). As the patient became more alert, she reported abdominal pain. A CT of the patient's abdomen and pelvis revealed mild to moderate ascites, bilateral small pleural effusions, bilateral atelectasis/pneumonia, hyperdense borderline enlarged spleen, and mild hepatomegaly. Ultrasonography of her kidneys revealed normal sized kidneys without hydronephrosis, and both main renal arteries and main renal veins were patent. However, given her worsening renal function, she was transferred to a quaternary care, pediatric hospital.
While hospitalized in the quaternary care hospital, her renal function improved. On HD 5, the patient was diagnosed with both acute respiratory distress syndrome and acute chest syndrome requiring endotracheal intubation. A respiratory culture identified human metapneumovirus. On HD 11, she was extubated and complained of visual changes including transient blindness. On HD 12, she became completely unresponsive, and she was reintubated. A head CT was unremarkable. Brain magnetic resonance imaging demonstrated hypoattenuation of posterior occipital and parietal lobes bilaterally consistent with posterior reversible encephalopathy syndrome or an ischemic event associated with sickle cell disease crisis. The patient was administered a nicardipine infusion for blood pressure control. She was extubated on HD 14 with gradual return to normal neurologic function. She was eventually discharged on HD 25. Through the help of social workers, pediatric hematology-oncology, and psychiatry, a plan was developed to have the patient's mother dispense all medications, and the patient was to follow up with specific school-based drug abuse programs as well as her psychiatrist.