Case Presentation: 41 year old male with a history of substance use (Phencyclidine/PCP) was brought to the hospital after being found nude and unconscious outside for an unknown period. At presentation he was awake but mute, not following commands nor tracking with his eyes. He was intermittently agitated. Exam notable for fever 103F, heart rate 110 beats/min, BP 160/90mmHg, respiratory rate 22 breaths/min, O2 saturation 98%. Pupils were 3mm and reactive to light, no nystagmus. He withdrew all extremities to painful stimuli, normal tone, brisk reflexes. CT head was normal. Urine drug screen was positive for PCP and marijuana. Laboratory studies showed normal CBC and BMP. ALT was 164 unit/L, AST 193 unit/L. CK was 9K unit/L initially, peaked at 29K by the third day. Troponin I was 0.6 ng/mL, peaked at 0.798 ng/mL. EKG showed junctional tachycardia. Notably patient’s mental status improved transiently when given low dose IV Ativan for agitation. He replied yes/no to questions and obeyed commands. He was diagnosed with PCP intoxication leading to catatonia, rhabdomyolysis, troponinemia, and drug induced liver injury. He was treated with acetaminophen and cooling blanket for fever, IV fluids, and low dose Ativan tablet daily. Over 4 days, vital signs normalized and mentation improved so Ativan was stopped. At discharge he was talking normally and ambulating. At primary care follow up he was doing well.
Discussion: PCP, or “angel dust”, is an anesthetic hallucinogenic drug. From 2005-2011, PCP-related emergency room visits increased 400%. PCP is a NMDA receptor antagonist affecting dopamine, norepinephrine and serotonin release and reuptake. PCP intoxication has both psychiatric and physical manifestations, presenting a diagnostic challenge. PCP effects depend on dose and method of ingestion. Most patients present with the classic toxidrome of violent behavior, nystagmus, tachycardia, and hypertension. Rare cases of severe intoxication can present with psychosis, catatonia, seizures, and coma; morbidities include rhabdomyolysis, renal failure, hypertensive crisis, malignant hyperthermia leading to acute hepatitis necrosis, and accidental trauma. Management is mostly supportive care. Benzodiazepine is the drug of choice for agitation and seizures. Cardiac and respiratory status should be monitored as PCP can induce cardiac arrhythmia or respiratory depression. Renal and liver function should also be monitored in setting of rhabdomyolysis or liver injury.
Conclusions: Altered mental status with catatonia seen in the hospital can have a psychiatric or medical etiology. Substance intoxication should be recognized as a cause in the right clinical context. Most cases of PCP intoxications are mild and can be monitored in observation; however severe PCP intoxication is associated with morbidity and mortality and need to be admitted for supportive care. With PCP’s growing popularity, hospital physicians should be familiar with PCP intoxication’s presentation and management.