RESUMO
The intracellular coccobacilli Rickettsia rickettsii causes Rocky Mountain Spotted Fever, a potentially fatal illness. This bacterium is transmitted to humans through a tick vector. Patients classically present with a triad of symptoms, including fever, headache, and a rash that begins on the extremities and spreads proximally to the trunk. Diagnosis of this disease can prove difficult when patients have unusual symptoms, such as hypertensive crisis. In this case report, we present a 29-year-old male who arrived at the emergency room with altered mental status and a hypertensive crisis after his family reported one week of changes in his behavior. The patient had no evidence of ticks, tick bites, fever, or rash. Positive findings in the emergency room included a WBC of 14.9 × 109. All other physical exams, imaging, and laboratory findings were non-contributory. The patient was promptly given IV hydralazine to control his blood pressure and empiric IV ceftriaxone for potential infection, and he was admitted for observation. Over the course of three days, WBC levels decreased, and his altered mental status improved. On day 3, the patient remembered a tick crawling across his hand, and this prompted the ordering of immunoglobulin levels for tick-borne illnesses. IgM for RMSF was positive. This case presentation illustrates the need for clinicians to keep the potential diagnosis of RMSF high on the differential, even in the presence of a paucity of symptoms, as prompt treatment with doxycycline can be lifesaving. This case may also be one of the first reported in the literature of hypertension being a symptom of Rocky Mountain Spotted Fever. It is plausible, however, that this patient's hypertension was due to an acute stress response.
RESUMO
Quetiapine, a pharmacological agent within the class of atypical antipsychotics, is characterized by its efficacy in mood stabilization and its role in the modulation of serotonergic and dopaminergic pathways. Its therapeutic utility is broad, encompassing the management of acute psychotic episodes, schizophrenia, bipolar disorder, and treatment-resistant depressive states. Quetiapine's effectiveness extends to depressive disorders that do not exhibit classic psychotic features, with a side effect profile that is less burdensome than many alternative psychotropic medications. Its versatility in addressing a range of psychiatric conditions is useful in the psychopharmacological management of mood and thought disorders. However, like all drugs, quetiapine may have different effects relative to the individual. It is imperative to approach the administration of quetiapine carefully, ensuring any adverse effects are ameliorated for beneficial therapeutic outcomes. In this case report, we present a psychosis-naive 42-year-old male who developed psychotic symptoms after beginning a quetiapine regimen in order to manage major depressive disorder with suicidal ideation. Clinical suspicion of quetiapine-induced psychosis was a diagnosis considered due to symptom remission secondary to ziprasidone in the place of quetiapine. The determination of a suspected adverse drug reaction can utilize the Naranjo scale to demonstrate the likelihood of an adverse drug reaction. This patient scored a three on the Naranjo scale, indicating a possible adverse effect from quetiapine. Other potential etiologies of psychosis include medication-induced psychosis, major depressive disorder exacerbation, cocaine use/withdrawal, and brief psychotic disorder. Quetiapine-induced psychosis has not been described in the current literature, and therefore, this case report is solely based on clinical evaluation and is intended for educational purposes due to possible confounding factors and etiologies.
