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• W2980952009 abstract "SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Cholinergic agonists are an important class of medications for patients with a variety of medical conditions including Sjogren’s disease and glaucoma, that if accidentally withheld, can have dire consequences. CASE PRESENTATION: An 83 year-old female with a history significant for Sjogren’s disease on pilocarpine, atrial fibrillation on Rivaroxaban, and recent small bowel obstruction presented to the hospital with abdominal pain and hypoxemia. Vital signs in the ED demonstrated hypotension, tachycardia, tachypnea and temperature of 103.1OC. She had leukocytosis, lactic acidosis and new acute kidney injury. CT scan chest and abdomen revealed nodular and patchy opacities within the right lung and a large ventral hernia without evidence of bowel obstruction. Intravenous fluids, empiric broad spectrum antibiotics, and vasopressors were initiated. She was intubated and transferred to the MICU with a working diagnosis of septic shock secondary to suspected hospital-acquired pneumonia. Infectious work up remained negative. Despite external cooling, temperatures between a low of 103 to maximum 107.2°F sustained over the subsequent 3 days. Endocrinologic and central nervous system etiologies for elevated temperature were ruled-out. Clonus and rigidity were not present, serum creatine kinase was normal, and empiric therapies for serotonin syndrome and neuroleptic malignant syndrome did not reduce the temperature. The patient expired on hospital day 4. DISCUSSION: Pilocarpine is a cholinergic agent, with muscarinic effects that aid in ciliary muscle contraction to increase aqueous humor drainage and hypersecretion of exocrine glands, which aid in saliva and sweat secretion. Sjogren’s syndrome patients use oral pilocarpine to treat symptoms of keratoconjunctivitis sicca and xerostomia. If withheld, these patients cannot produce tears or perspire. Consequently, this can lead to irreversible blindness, anhidrosis, and hyperthermia. Sweating is a fundamental mechanism for eliminating body heat. Abrupt pilocarpine withdrawal leads to impaired thermoregulation through absence of sweating. Oral pilocarpine was abruptly held in our patient because of a recent small bowel obstruction. As all other causes of hyperthermia were evaluated and excluded, Pilocarpine withdrawal was implicated. Review of the literature reveals no documented case reports of fatal Pilocarpine withdrawal in humans, and only 1 case of status-epilepticus in an animal model. Treatment is currently not well studied or documented in the literature, though presumed to be reversible with re-administration of Pilocarpine. CONCLUSIONS: Pilocarpine is a muscarinic agent chronically used, for example, as a sialagogue in Sjogren’s. In the right clinical context, clinicians should maintain a high index of suspicion for pilocarpine withdrawal as it may lead to impaired thermoregulation, elevated body temperature, and death. Reference #1: Watanabe et al. Journal of Pharmaceutical Health Care and Sciences (2018) 4:4 DOI:10.1186/s40780-018-0099-x Reference #2: Arch Intern Med. 1999;159:174-181 DISCLOSURES: No relevant relationships by Rasika Chepuri, source=Web Response No relevant relationships by Toni-Denise Espina, source=Web Response No relevant relationships by Jayshil Patel, source=Web Response" @default.
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• W2980952009 date "2019-10-01" @default.
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• W2980952009 title "IT'S BURNING UP IN HERE" @default.
• W2980952009 doi "https://doi.org/10.1016/j.chest.2019.08.1617" @default.
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