Clinical communication
Intrathecal baclofen withdrawal mimicking sepsis

https://doi.org/10.1016/S0736-4679(03)00039-8Get rights and content

Abstract

Baclofen (Lioresal™) is a drug of choice to treat spasticity and is increasingly being administered intrathecally via an implantable pump in cases refractory to oral therapy. Emergency physicians will likely treat patients with baclofen withdrawal or overdose as this treatment becomes more widespread. The syndrome of baclofen withdrawal presents with altered mental status, fever, tachycardia, hypertension or hypotension, seizures, and rebound spasticity, and may be fatal if not treated appropriately. Baclofen withdrawal may mimic other diseases including sepsis, meningitis, autonomic dysreflexia, malignant hyperthermia, or neuroleptic malignant syndrome. Treatment consists of supportive care, reinstitution of baclofen, benzodiazepines, and diagnosis and eventual repair of intrathecal pump and catheter malfunction.

Introduction

Baclofen is a gamma amino butyric acid (GABA) analog with inhibitory effects on the brain and spinal cord reflexes. It is the drug of choice to treat spasticity and is increasingly being administered intrathecally via an implantable pump in cases refractory to oral therapy. Because baclofen pumps are being implanted with increasing frequency, it is likely that emergency physicians will treat patients with baclofen overdose or withdrawal. Baclofen withdrawal may mimic other illnesses. To illustrate this, we present a case of acute baclofen withdrawal that was misdiagnosed as sepsis.

Section snippets

Case report

A 4-year-old boy with history of prematurity, seizure disorder, and spastic quadriparesis presented to the Emergency Department (ED) with the chief complaint of respiratory distress. Thirteen months before this admission, he had an intrathecal baclofen pump implanted for spasticity refractory to oral therapy. In the ED, the rectal temperature was 39.8°C (103.7°F); heart rate (HR) 130 beats/min, respiratory rate 40–50 breaths/min, systolic blood pressure (SBP) 140 mm Hg, and oxygen saturation

Discussion

Our case illustrates baclofen withdrawal, a syndrome similar to benzodiazepine withdrawal and characterized by fever, tachycardia, seizures, spasticity, and autonomic instability (1). The clinical picture was difficult to distinguish from sepsis but resolved rapidly once the diagnosis was made and baclofen therapy was reinstituted. The diagnosis of baclofen withdrawal is often difficult, as many patients may be unable to provide a history. Furthermore, physical examination may miss a small

Summary

The clinical syndrome of baclofen withdrawal must be recognized, as the diagnosis may be clinically occult and treatment may be life saving. Treatment consists of supportive care, reinstitution of baclofen, benzodiazepines, and diagnosis and eventual repair of intrathecal pump and catheter malfunction.

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Clinical Communications (Pediatrics) is coordinated by Roger Barkin, md, of HealthONE, Denver, Colorado and Ghazala Q. Sharieff, md, of the University of Florida, Jacksonville, Florida

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