CASE: Agitated and violent
Police bring Ms. Y, age 42, to the emergency room (ER) after her boyfriend calls 911 because she is physically aggressive. The police note that the home is in disarray and several windows are broken. Ms. Y is threatening and violent—she bites and spits at her boyfriend and the police. The ER assessment reports that she is “agitated, confused, and not making sense.” She receives IV haloperidol, 5 mg, for agitation and aggressive behavior, but does not improve and receives a second dose of haloperidol approximately 1 hour later.
On examination she is afebrile. Laboratory results are notable for elevated blood urea nitrogen (27 mg/dL) and creatinine (2.3 mg/dL), suggesting renal failure. Her white blood cell (WBC) count is elevated at 14.7 K/μL with increased neutrophil count. Her creatine phosphokinase (CPK) also is elevated at 2,778 U/L. Other lab results, including liver function tests and a rapid plasma reagin, are within normal limits. Urinalysis reveals WBC >50 and leukocyte esterase 3+ WBC/μL. Urine drug screen is negative for barbiturates, benzodiazepines, opiates, and cocaine and her blood alcohol level is <10 mg/dL. She is overweight, but not obese. Ms. Y is admitted to the medical service for workup of rhabdomyolysis and altered mental status.
When the psychiatric consultation-liaison (CL) service evaluates Ms. Y 12 hours after presentation, she is disheveled, drowsy, and lying in bed, with multiple superficial lacerations on her forearms. She is cooperative but claims to have no recollection of the events leading up to her admission. Her speech is soft with a lack of spontaneity, and she demonstrates substantial psychomotor retardation. Her mood is irritable and affect is restricted. She has a latency of thought and difficulty recalling basic historic information. Ms. Y appears confused and frequently responds to questions with “I don’t remember.” She seems frustrated and distressed by her inability to answer questions. She denies suicidal or homicidal ideation and auditory or visual hallucinations, although she appears to be responding to internal stimuli. We cannot complete a Mini-Mental State Exam because she becomes uncooperative. After 10 minutes, Ms. Y ends the interview, stating that too much is being “demanded” of her.
The authors’ observations
Ms. Y’s acute-onset agitation and confusion could be caused by an infection, such as a urinary tract infection, a frequent culprit in delirium or transient psychosis. Seizure activity with postictal confusion also has to be included in the differential, as well as an endogenous psychotic disorder such as schizophrenia or a manic bipolar episode. Ms. Y’s boyfriend of 16 months indicated that Ms. Y uses alcohol but cannot quantify the amount or frequency. We considered and ruled out other intoxicant use as a potential cause of her transient psychosis. An extended drug screen was negative and her lab values did not suggest heavy alcohol use.
HISTORY: Past psychotic episodes
Ms. Y’s boyfriend reports that she had 2 psychiatric hospitalizations approximately 30 years ago, which were precipitated by psychotic symptoms that she developed while abusing drugs. To the best of his knowledge Ms. Y had not used these agents recently. He stated that Ms. Y did not appear to have ongoing psychotic symptoms and had not received psychiatric treatment since she was a teenager until 6 months ago. He describes the current hospitalization as being “just like 6 months ago.”
Medical records reveal that Ms. Y was admitted to our hospital 6 months ago because she was acting violently and combative. She was “talking out of context,” “stated that she was God,” and had auditory hallucinations. She was admitted to the medical service for rhabdomyolysis, which was thought to be caused by hyperactivity or exertion. Ms. Y indicated that she was taking food supplements, including L-carnitine, to help lose weight. Her psychotic symptoms cleared within 24 hours and she was discharged without any psychiatric medications. Her behavioral disturbance was attributed to ingesting excessive amounts of carnitine supplements, and Ms. Y was counseled to abstain from them.
The authors’ observations
Carnitine is a common dietary supplement that is advertised as being safe and effective.1 It is purported to increase fat oxidation or reduce fat synthesis; however, no trials demonstrate that L-carnitine is effective for weight loss (Box).2-7 Evidence from well-designed randomized, controlled clinical trials indicates that the safe upper limit of long-term intake is 2,000 mg/d of L-carnitine equivalents.8 The data for doses >2,000 mg/d are not sufficient to make a confident conclusion on long-term safety.8