A 26‐year‐old woman was found unresponsive and surrounded by peritoneal dialysate. She was last known to be conscious 12 hours prior. Past medical history includes uncontrolled type I diabetes mellitus, hypertension, depression, schizoaffective disorder, and end stage renal disease on peritoneal dialysis. Medications include nitrofurantoin, escitalopram, furosemide, gabapentin, hydrocodone‐acetaminophen, insulin, buspirone, clonidine, lorazepam, quetiapine, and venlafaxine, among others. She smokes cigarettes and has occasional alcohol but has no known history of illicit substance abuse per her mother. Temperature was 39°C, blood pressure 225/115, pulse 108 bpm, and respiratory rate 18 breaths per minute. Exam revealed a restless female, moving all 4 extremities with focal deficit, dilated pupils with sluggish responses, tachycardia, and a clean peritonea dialysis site. Noncontrasl computed tomography of the head failed to demonstrate a cause for the change in mentation. Neutrophilia without leukocytosis and normal blood glucose were found on laboratory studies. Urine drug screen was positive for cocaine and opiates. Cerebrospinal fluid analysis showed glucose 332 mg/dL, protein 67 mg/dL, white blood cells 169 mm3 with 99% neutrophils and red blood cells 29/mm3. CSF gram stain was positive for white cells only; subsequent blood and fluid cultures were negative. The patient was treated with antibiotics, antihypertensives and subsequently regained consciousness to her baseline.
Hyperthermia and seizures caused by acute cocaine intoxication can initially imitate meningitis. However it must be kept in mind that generalized seizures produce a transient CSF pleocytosis and should be considered when there is no clear clinical or laboratory evidence for meningitis. Cocaine increases circulating levels of epinephrine and norepinephrine up to 5 times and causes overstimulation of the sympathetic nervous system. The drug also inhibits serotonin reuptake in the synaptic cleft of neurons causing an accumulation. The above combination is thought to induce generalized and focal seizures. A lowered seizure threshold is especially dangerous in patients who are susceptible.
By affecting the central thermal regulatory system, cocaine causes hyperthermia, which can also give rise to epileptiform activity. Although meningitis is a more dreaded diagnosis, cocaine intoxication can produce similar symptoms which can progress rapidly if not recognized and treated appropriately.
V. Faridani, none; K. Khosa, none: R. Beirne, none.