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Difficulty: MediumSubstance-Related and Addictive Disorders

Match each patient's clinical presentation with the most likely substance-related toxidrome or diagnosis.

  • Prolonged and severe delirium, extreme combativeness, myoclonus, and autonomic hyperactivity lasting for over 48 hoursSynthetic cathinone intoxication
  • Transient euphoria, lethargy, ataxia, depressed reflexes, and an erythematous perioral rashInhalant intoxication
  • Acute onset of severe chest pain, prominent pupillary dilation, diaphoresis, and a blood pressure of 185/115 mm HgCocaine intoxication
  • Increased sociability, euphoria, bruxism, hyperthermia, and acute hyponatremiaMDMA (ecstasy) intoxication
  • Tremors, marked anxiety, perceptual disturbances, and a generalized tonic-clonic seizure following abrupt medication cessationBenzodiazepine withdrawal

Answer

Matching these distinct clinical presentations to their corresponding substance-related diagnosis relies on identifying pathognomonic or highly characteristic clinical features, such as prolonged delirium for synthetic cathinones, a perioral rash for inhalants, and hyponatremia for MDMA.
Each specific clinical vignette contains hallmark signs pointing to a distinct toxidrome. Synthetic cathinones cause an uncharacteristically prolonged delirium; inhalants cause a characteristic perioral rash; cocaine causes intense vasospasm and ischemic chest pain; MDMA induces bruxism and hyponatremia; and abrupt benzodiazepine cessation results in severe withdrawal seizures.

Step-by-Step Solution

1
Evaluate the first presentation for distinguishing features.
The prolonged duration (>48 hours) of severe agitation and combativeness is the key finding.
This exceptionally long duration of delirium uniquely points to synthetic cathinone intoxication over typical short-acting stimulants.
2
Analyze the second presentation focusing on dermatologic findings.
The combination of transient depressant effects and an erythematous perioral rash is identified.
The 'glue sniffer's rash' is a highly specific physical exam finding for chronic inhalant abuse.
3
Assess the third presentation involving cardiovascular pathology.
The acute chest pain accompanied by extreme hypertension and mydriasis is isolated.
Cocaine-induced coronary vasospasm is a classic and dangerous cause of acute chest pain in the setting of extreme sympathetic overactivation.
4
Examine the fourth presentation for unique metabolic and behavioral signs.
Increased sociability, bruxism, and hyponatremia are grouped together.
MDMA classically causes bruxism and is well known to cause potentially life-threatening hyponatremia.
5
Review the fifth presentation regarding medication cessation.
The onset of tremors, anxiety, and a generalized tonic-clonic seizure is noted.
Abrupt discontinuation of central nervous system depressants, specifically benzodiazepines or alcohol, leads to rebound excitation and withdrawal seizures.

Key Concept

Distinguishing characteristics of various substance intoxications and withdrawals based on unique physical exam and metabolic findings.
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Topics

Substance-Related and Addictive Disorders

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