Post-Ictal Psychosis Following Polysubstance Overdose
Poster #: 060
Session/Time: A
Author:
Bhavana Madhu, BS
Mentor:
David Spiegel, MD
Research Type: Case Report
Abstract
INTRODUCTION:
We present a rare case of postictal psychosis (PP) arising after overdose-induced seizures in a patient without a history of epilepsy. While PP is classically described in individuals with chronic temporal lobe epilepsy, reports of PP specifically following overdose-induced new-onset seizures remain scarce; to our knowledge, no prior case describes PP after a mixed ingestion of quetiapine, hydroxyzine, sertraline, amlodipine, and atorvastatin.
CASE INFORMATION:
Case-based observational analysis. A 33-year-old male with a history of MDD, anxiety, and OCD presented to the emergency department after a suicide attempt involving laceration of his left wrist and ingestion of approximately 100 pills which included a mix of amlodipine, hydroxyzine, sertraline, quetiapine, and atorvastatin. Both BAL and UDS were unremarkable. He was hypotensive and required transfusion of two units of whole blood. He was initially aggressive with staff and intermittently endorsed seeing "a demon," though he denied auditory hallucinations. On hospital day 2, he experienced two generalized seizures attributed to toxic ingestion: the first seizure resolved spontaneously while the second was resolved with 2 mg midazolam. EEG performed later that day showed bifrontal sharp transients without epileptiform correlate, and MRI of the brain was unremarkable. Following the seizures, he developed acute kidney injury progressing to dialysis dependence, with creatinine peaking at 17.7 mg/dL. Over the subsequent days, he exhibited waxing and waning confusion, severe agitation requiring physical restraints, paranoid delusions, and visual hallucinations of demonic images. This case highlights postictal psychosis (PP) as the most likely diagnosis. Despite broad infectious, autoimmune, and paraneoplastic workup, no alternative etiology was identified. Notably, NMDA and other neuronal antibody panels were negative, and lumbar puncture was nondiagnostic. By hospital day 16, his agitation subsided and all antipsychotics were discontinued. He was discharged home in stable condition, alert and oriented ×3, without recurrence of psychotic symptoms.
DISCUSSION:
Although our patient displayed some visual hallucinations prior to his seizures, his rapid progression to florid psychosis in the days immediately following the seizures, absence of infectious or autoimmune causes, and eventual full remission are consistent with the natural course of PP. In overdose scenarios, certain medications such as SSRIs, antihistamines, and antipsychotics can greatly lower the seizure threshold. Several of the agents ingested in this case are known to lower seizure threshold and provoke neuropsychiatric complications in overdose. Quetiapine overdose has been linked to late-onset generalized seizures, hydroxyzine toxicity has been associated with seizures, delirium, and hallucinations, and sertraline overdose has been implicated in seizures and serotonin-related agitation with visual phenomena. While seizure activity is a known complication of overdose with these agents, postictal psychosis remains a poorly understood phenomenon.
CONCLUSION:
The report expands awareness of PP beyond epilepsy populations, highlights diagnostic challenges when psychiatric and toxicologic factors overlap, and emphasizes the need for clinicians to recognize PP as a potential complication in overdose presentations.
We present a rare case of postictal psychosis (PP) arising after overdose-induced seizures in a patient without a history of epilepsy. While PP is classically described in individuals with chronic temporal lobe epilepsy, reports of PP specifically following overdose-induced new-onset seizures remain scarce; to our knowledge, no prior case describes PP after a mixed ingestion of quetiapine, hydroxyzine, sertraline, amlodipine, and atorvastatin.
CASE INFORMATION:
Case-based observational analysis. A 33-year-old male with a history of MDD, anxiety, and OCD presented to the emergency department after a suicide attempt involving laceration of his left wrist and ingestion of approximately 100 pills which included a mix of amlodipine, hydroxyzine, sertraline, quetiapine, and atorvastatin. Both BAL and UDS were unremarkable. He was hypotensive and required transfusion of two units of whole blood. He was initially aggressive with staff and intermittently endorsed seeing "a demon," though he denied auditory hallucinations. On hospital day 2, he experienced two generalized seizures attributed to toxic ingestion: the first seizure resolved spontaneously while the second was resolved with 2 mg midazolam. EEG performed later that day showed bifrontal sharp transients without epileptiform correlate, and MRI of the brain was unremarkable. Following the seizures, he developed acute kidney injury progressing to dialysis dependence, with creatinine peaking at 17.7 mg/dL. Over the subsequent days, he exhibited waxing and waning confusion, severe agitation requiring physical restraints, paranoid delusions, and visual hallucinations of demonic images. This case highlights postictal psychosis (PP) as the most likely diagnosis. Despite broad infectious, autoimmune, and paraneoplastic workup, no alternative etiology was identified. Notably, NMDA and other neuronal antibody panels were negative, and lumbar puncture was nondiagnostic. By hospital day 16, his agitation subsided and all antipsychotics were discontinued. He was discharged home in stable condition, alert and oriented ×3, without recurrence of psychotic symptoms.
DISCUSSION:
Although our patient displayed some visual hallucinations prior to his seizures, his rapid progression to florid psychosis in the days immediately following the seizures, absence of infectious or autoimmune causes, and eventual full remission are consistent with the natural course of PP. In overdose scenarios, certain medications such as SSRIs, antihistamines, and antipsychotics can greatly lower the seizure threshold. Several of the agents ingested in this case are known to lower seizure threshold and provoke neuropsychiatric complications in overdose. Quetiapine overdose has been linked to late-onset generalized seizures, hydroxyzine toxicity has been associated with seizures, delirium, and hallucinations, and sertraline overdose has been implicated in seizures and serotonin-related agitation with visual phenomena. While seizure activity is a known complication of overdose with these agents, postictal psychosis remains a poorly understood phenomenon.
CONCLUSION:
The report expands awareness of PP beyond epilepsy populations, highlights diagnostic challenges when psychiatric and toxicologic factors overlap, and emphasizes the need for clinicians to recognize PP as a potential complication in overdose presentations.