A Case of Severe Fioricet Withdrawal Presenting During Admission to an Inpatient Psychiatric Unit.

BACKGROUND: Butalbital-containing combination (BCC) analgesics have the potential for the development of tolerance and dependence. Misuse and withdrawal of these agents should be considered in patients presenting with new-onset psychosis. This case highlights how butalbital withdrawal may be missed in the emergency department setting and underscores how early identification may affect management and prognosis. Case Presentation. A 40-year-old female with a history of migraine, depression, and anxiety presented to the emergency department (ED) with new-onset psychosis following a recent seizure-like episode. At home, the patient was prescribed butalbital-acetaminophen-caffeine (Fioricet), duloxetine, alprazolam, and zolpidem for these conditions. On arrival to the ED, the patient was disoriented and appeared to be responding to internal stimuli. Following initial medical evaluation, the patient was cleared for further psychiatric assessment, during which she developed acute-onset autonomic instability while waiting for a bed on the inpatient psychiatric unit. She then became agitated, requiring multiple emergency medications, and eventually required emergent intubation and was admitted to the intensive care unit (ICU). Following extubation, a psychiatric consultation was performed. On assessment, the patient was alert and oriented and no longer exhibited psychotic symptoms. She admitted to using butalbital-acetaminophen-caffeine (Fioricet) daily for the past 10 years and had recently run out of her prescribed medication. She acknowledged that she was taking more than prescribed and requested substance use treatment resources, for which she was subsequently discharged to an inpatient drug rehabilitation facility. CONCLUSIONS: Given the time constraints inherent to the ED setting, a complete substance use history (both illicit and prescribed) may be challenging to obtain. However, it remains critical for providers to identify patients at risk for life-threatening withdrawal from sedative, hypnotics, and anxiolytic agents.

A 21-day-old boy with an annular eruption. Tinea faciei / Tinea capitis.

A healthy 21-day-old black male was referred to pediatric dermatology for evaluation of a facial and scalp eruption that had been present for less than 1 week. The child's parents had applied a topical corticosteroid cream for several days without any improvement noted. The child was otherwise well and thriving. Review of systems was negative. Family history was unremarkable for autoimmune or infectious skin diseases. On physical examination the patient was alert, active, and vigorous. He had multiple 1 to 2.5-cm erythematous annular, scaly plaques with pustules on the periphery on his upper cheeks, forehead, and anterior scalp (Figures 1-2). No alopecia was noted. Occipital and neck lymph nodes were not palpable. A potassium hydroxide skin preparation was negative for fungal elements and a fungal culture was performed. Serum laboratory testing was also performed.

Screening breast MR imaging: comparison of interpretation of baseline and annual follow-up studies.

PURPOSE: To determine whether baseline screening breast magnetic resonance (MR) imaging studies have a higher rate of follow-up or biopsy recommendation than do studies with prior MR images available for comparison. MATERIALS AND METHODS: This was an institutional review board-approved, HIPAA-compliant, retrospective study. Informed consent was waived. Reports from 650 consecutive screening breast MR imaging examinations performed in women between September 2007 and December 2008 were reviewed. All examinations were performed by using the same protocol, and images were interpreted by the same radiologists. Presence of comparison studies, Breast Imaging Reporting and Data System (BI-RADS) category, and biopsy results were recorded. Data were analyzed by using the χ(2) test, the two-sample test of proportions, and the Fisher exact test. RESULTS: Mean patient age was 51 years (range, 25-81 years). Of the baseline studies, findings in 31 of 307 (10.1%) were interpreted as BI-RADS category 3 and findings in 18 of 307 (5.9%) were interpreted as BI-RADS category 4 or 5. Of the examinations with findings classified as BI-RADS category 4 or 5, the results in two of 18 (11.1%) were positive for malignancy at biopsy. Of the examinations with prior MR images for comparison, findings in nine of 343 (2.6%) were interpreted as BI-RADS category 3 and findings in 16 of 343 (4.7%) were interpreted as BI-RADS category 4 or 5. Of the examinations with findings classified as BI-RADS category 4 or 5, the results in three of 16 (18.8%) were positive for malignancy at biopsy. The difference in the number of BI-RADS category 3 interpretations between the two groups was significant (P < .001), but there was no significant difference in BI-RADS category 4 or 5 interpretations or positive predictive values. CONCLUSION: Baseline screening MR imaging was associated with a higher likelihood of recommendation for short-interval follow-up than was MR imaging with prior images for comparison.