A 32-year-old male landscape architect is evaluated in the emergency department after his … — USMLE Step 2 CK

A 32-year-old male landscape architect is evaluated in the emergency department after his husband called emergency services. The patient has refused to eat for three days and states he feels "hollow and hopeless." He reports a 4-week history of severe anhedonia, hypersomnia, and a $5 \text{ kg}$ weight gain. Four years ago, he experienced a 3-week period where he slept only 3 hours per night, spoke rapidly, and recklessly spent his life savings on a failing business venture. He is currently on day 8 of a 10-day course of oral linezolid for a methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation and a blunted affect, but he is alert, oriented, and answers questions coherently. He denies hallucinations or delusions. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $3.9 \text{ \mu U/mL}$ (reference: $0.4-4.2 \text{ \mu U/mL}$ ) and a free T4 of $1.2 \text{ ng/dL}$ (reference: $0.8-2.7 \text{ ng/dL}$ ). Which of the following is the most appropriate next step in management?

Initiate quetiapineCevap
B
Initiate sertraline
C
Initiate levothyroxine
D
Initiate haloperidol
E
Obtain consent for electroconvulsive therapy from the husband

Cevap

Initiate quetiapine

The correct intervention is to initiate quetiapine. This patient presents with an acute depressive episode but has a clear history of a manic episode (decreased sleep, rapid speech, reckless spending resulting in severe financial impairment), establishing a diagnosis of Bipolar I Disorder. The first-line pharmacological treatments for acute bipolar depression include certain second-generation antipsychotics (quetiapine, lurasidone, cariprazine) or mood stabilizers (lithium, valproate). Quetiapine effectively targets bipolar depression without the risk of inducing a manic switch. Furthermore, it is safe to use with his current linezolid therapy, avoiding the severe risk of serotonin syndrome that standard antidepressants would pose.

Adım Adım Çözüm

Diagnose the current psychiatric episode based on the clinical presentation.

The patient is experiencing a severe Major Depressive Episode (anhedonia, hypersomnia, weight gain, psychomotor retardation).

Identifying the current syndrome is required to target acute therapy.

Analyze the psychiatric history for prior mood episodes.

The patient had a discrete 3-week episode of decreased need for sleep, rapid speech, and reckless behavior causing severe impairment (loss of life savings).

This confirms a history of a Manic Episode, establishing the overarching diagnosis of Bipolar I Disorder.

Evaluate the patient's current medication list for potential pharmacological interactions.

The patient is taking linezolid, which possesses reversible monoamine oxidase inhibitor (MAOI) activity.

MAOIs interact fatally with serotonergic agents (like SSRIs), causing Serotonin Syndrome.

Select the safest and most effective pharmacotherapy for Bipolar I Depression.

Quetiapine is selected.

Quetiapine is FDA-approved for bipolar depression, does not induce manic switching (unlike SSRIs), and avoids the severe serotonergic interactions associated with linezolid.

Anahtar Kavram

The management of acute bipolar depression requires mood-stabilizing agents (such as quetiapine, lurasidone, or cariprazine) and strict avoidance of antidepressant monotherapy to prevent manic switching. Comorbid medications, such as linezolid (an MAOI), must also be evaluated to avoid fatal drug interactions.

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