Toxic confusional state

Gastro intestinal bleeding, acute pancreatitis, a toxic confusional state, and acute hepatistis/hepatic failure are each possible results of a very heavy drinking binge . Heredity appears to play a major role in the contraction of alcoholism, with recent discoveries of genes that influence vulnerability to this disorder. 

It is indicated in wet beriberi, dry beriberi, Wernicke s encephalopathy, prophylaxis of thiamine deficiency, hyperemesis gravidarum, Korsakoff s syndrome, chronic alcoholics, multiple neuritis, toxic and confusional states, delirium tremens and anorexia nervosa. 

Use of androgenic steroids is likely to produce a sensation of energy and euphoria, but also with a tendency to sleeplessness and irritability (1). More extreme changes in mental state can result in extreme swings in mood, ranging from depression to aggressive elation. An unusual complication in one case was a toxic confusional state and choreiform movements caused by an anabolic steroid (SED-12, 1038) (29), but it may have been due to the non-specific results of endocrine stress in a susceptible individual. 

Tilzey A, Heptonstall J, Hamblin T. Toxic confusional state and choreiform movements after treatment with anabolic steroids. BMJ (Chn Res Ed) 1981 283(6287) 349-50. 

Mania can occur in any age group. Acute manic episodes in the elderly may best be managed with high potency neuroleptics. The use of lithium is not contraindicated in the elderly provided renal clearance is reasonably normal. The dose administered should be carefully monitored, as the half-life of the drug is increased in the elderly to 36-48 hours in comparison to about 24 hours in the young adult. The serum lithium concentration in the elderly should be maintained at about 0.5 mEq/litre. It is essential to ensure that the elderly patient is not on a salt-restricted diet before starting lithium therapy. The side effects and toxicity of lithium have been discussed in detail elsewhere (see p. 198 et seq.), and, apart from an increase in the frequency of confusional states in the elderly patient, the same adverse effects can be expected as in the younger patient. 

As little as 8 mg/day combined with levodopa has caused an acute toxic confusional state in some patients. 

Delirium, toxic confusional state, metabolic encephalopathy or acute confusional state are terms that are used interchangeably and often loosely to describe a syndrome of acutely disordered cognition, sometimes associated with reduced level of consciousness and abnormal attention (see Table 32.1). The syndrome is very common, especially in the elderly and in patients with dementia, and presentations vary widely both in the speed of onset and severity (Siddiqi et al. 2006). The differential diagnosis is broad and includes almost any medical condition, but the commonest causes are sepsis, adverse drug reaction and metabolic derangement (Francis et al. 1990). 

Unwanted effects include dry mouth, blurred vision, constipation, urine retention, glaucoma, hallucinations, memory defects, toxic confusional states and psychoses (which should be distinguished from presenile dementia). 

Procyclidine is an anticholinergic drug (1). The usual oral dose, which lies between 20 and 30 mg/day, is likely to produce only mild anticholinergic adverse effects, but involuntary movements, with chewing and sucking, have been described in some patients (SEDA-1, 120). Even small doses have produced toxic confusional states when procyclidine was combined with phenothiazines for schizophrenia. Procyclidine is more hkely to produce sedation than stimulation. 

B. Severe intoxication may cause coma, seizures, and respiratory arrest. The ECG may show QTc interval prolongation and occasionally QRS prolongation (particularly with thioridazine [Mellaril]). Hypothennia or hyperthennia may occur. Clozapine can cause a prolong confusional state and rarely cardiac toxicity. 

Twelve patients with parkinsonism on levodopa plus a dopa-decarboxylase inhibitor were additionally given baclofen. The eventual baclofen dosage was intended to be 90 mg daily, but the adverse effects were considerable (visual hallucinations, a toxic confusional state, headaches, nausea) so that only 2 patients reached this dosage, and 2 patients withdrew because they could not tolerate these adverse effects. The mean dosage for those who continued was 45 mg daily. Rigidity was aggravated by an average of 46% and functional capacity deteriorated by 21%. ... 

In a double-blind study 3 patients given a phenothiazine and benzatropine for the parkinsonian adverse effects, developed an intermittent toxic confusional state (marked disturbance of short-term memory, impaired attention, disorientation, anxiety, visual and auditory hallucinations) with peripheral antimusearinies signs. Similar reactions occurred in 3 elderly patients given imipramine or desipramine, with trihexyphenidyl, and in another man given chlorpromazine, benzatropine and doxepin. ... 

Adverse effects from topical application of podophyllin have been reported and include erythema, edema, chemical burns, and allergic sensitivity. Systemic toxicity may cause nausea, vomiting, respiratory stimulation, peripheral neuropathy, fever, acute confusional states, tachycardia, oliguria, adynamic ileus, leukopenia, elevation of liver enzymes, coma, and death (Miller 1985 Rudrappa and Vijaydeva 2002). 

These confusional states resemble the antichoUnergic syndrome previously identified as a toxic effect of belladonna alkaloids, and also relieved by physostigmine. The mechanism by which physostigmine reverses this effect of benzodiazepines is not known. A similar reversal of diazepam toxicity has been achieved using naloxone, but again the mechanism cannot be explained. 

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