An Atypical Case of Neuroleptic Malignant Syndrome Associated With Ciprofloxacin and Quetiapine.

A 29-year-old male presented to the emergency department with complaints of shortness of breath and numbness in bilateral upper and lower extremities that started a few hours prior to arrival. On physical examination, the patient was afebrile, disoriented, tachypneic, tachycardic, and hypertensive with generalized muscle rigidity. Further investigation revealed that the patient had recently been prescribed ciprofloxacin and restarted on quetiapine. The initial differential diagnosis was acute dystonia, and subsequently, the patient was placed on fluids, lorazepam, diazepam, and later benztropine. The patient's symptoms began to resolve, and psychiatry was consulted. Given the patient's autonomic instability, altered mental status, muscle rigidity, and leukocytosis, psychiatric consultation revealed an atypical case of neuroleptic malignant syndrome (NMS). It was postulated that the patient's NMS was caused by a drug-drug interaction (DDI) between ciprofloxacin, a moderate cytochrome P450 (CYP) 3A4 inhibitor, and quetiapine, which is primarily metabolized by CYP3A4. The patient was then taken off quetiapine, admitted overnight, and discharged the next morning with complete resolution of his symptoms along with a prescription for diazepam. This case highlights the variable presentation of NMS and the need for clinicians to consider DDI when managing psychiatric patients.

An Unusual Case of Deep Vein Thrombosis and Concurrent Necrotizing Fasciitis Following a Fall.

A 74-year-old male patient presented to the emergency department following a fall with signs and symptoms consistent with right lower extremity (RLE) deep vein thrombosis (DVT) and non-specific skin changes. Further imaging confirmed the initial diagnosis of DVT, and the patient was appropriately treated. However, his condition continued to deteriorate with worsening overlying skin changes, which prompted a computed tomography (CT) scan of his right femur without intravenous (IV) contrast. This revealed fluid tracking along the lateral compartment muscles, which raised suspicion of an abscess. Suspicion for necrotizing fasciitis (NF) was raised with a subsequent CT of the right femur with IV contrast that demonstrated a considerable increase in rim-enhancing fluid collections intramuscularly and extending into both the anterior and posterior compartments, likely correlating with increasing intermuscular abscesses. On imaging, no subcutaneous emphysema or gas accumulation was found, which is a common finding in NF. However, necrotic-appearing muscle was found on surgical debridement and wound cultures confirmed the diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) NF. The patient was then treated with appropriate IV antibiotics and was discharged to long-term inpatient wound care. Similar presentations of DVT and NF made a prompt diagnosis of NF difficult, and it highlights the need for further imaging to rule out NF when a patient has a confirmed diagnosis of DVT.