title: Intrathecal Clonidine Pump Failure Causing Acute Withdrawal Syndrome With 'Stress-Induced' Cardiomyopathy.
abstract: Clonidine is a central alpha(2)-agonist antihypertensive used widely for opioid/alcohol withdrawal, attention deficit hyperactivity disorder and chronic pain management. We describe a case of clonidine withdrawal causing life-threatening hypertensive crisis and stress-induced cardiomyopathy. A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24 h), presented following a collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump malfunctioned. On presentation, vital signs included pulse 100 bpm, BP 176/103 mmHg, temperature 37.8 °C and O2 saturation 100 % (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. Intravenous clonidine loading dose and a 50 mcg/h infusion were commenced. Five hours later, severe chest pain, dyspnoea, tachycardia, hypoxia, with BP 180/120 mmHg and pulmonary edema ensued. ECG showed sinus tachycardia with no ST elevation. Repeated intravenous clonidine doses were given (25 mcg every 5-10 min), with ongoing clonidine infusion to control blood pressure. Glyceryl trinitrate infusion, positive pressure ventilation and intravenous benzodiazepines were added. Bedside echocardiogram showed stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. His coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in the ICU, drug infusions were weaned. Discharge was 12 days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone-SR. Two months later, his echocardiogram was normal. The intrathecal pump was removed. We report a case of stress-induced cardiomyopathy resulting from the sudden cessation of long-term intrathecal clonidine. This was managed by re-institution of clonidine and targeted organ-specific therapies.
authors.affiliation: Monash Health Clinical Toxicology and Addiction Medicine Service, Monash, Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia. hweeminlee@gmail.com.|Monash Emergency Program, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia. hweeminlee@gmail.com.|School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia. hweeminlee@gmail.com.|Department of Emergency Medicine, Dandenong Hospital, 135 David Street, Dandenong, VIC, Australia. hweeminlee@gmail.com.
authors.forename: Hwee Min D
authors.initials: HM
authors.lastname: Lee
authors.affiliation: Monash Health Clinical Toxicology and Addiction Medicine Service, Monash, Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.|Monash Emergency Program, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.
authors.forename: Varuna
authors.initials: V
authors.lastname: Ruggoo
authors.affiliation: Monash Health Clinical Toxicology and Addiction Medicine Service, Monash, Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.|Monash Emergency Program, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.|School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia.
authors.forename: Andis
authors.initials: A
authors.lastname: Graudins
mesh_terms: D058647:Adrenergic alpha-2 Receptor Agonists / Q000008:administration & dosage / Q000009:adverse effects*; D001416:Back Pain / Q000175:diagnosis / Q000188:drug therapy*; D059350:Chronic Pain / Q000175:diagnosis / Q000188:drug therapy*; D003000:Clonidine / Q000008:administration & dosage / Q000009:adverse effects*; D004562:Electrocardiography; D004868:Equipment Failure; D006801:Humans; D015918:Infusion Pumps, Implantable; D060186:Infusions, Spinal; D008297:Male; D008875:Middle Aged; D013375:Substance Withdrawal Syndrome / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D054549:Takotsubo Cardiomyopathy / Q000139:chemically induced* / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy
chemical_list: D058647:Adrenergic alpha-2 Receptor Agonists; D003000:Clonidine
keywords: Cardiomyopathy; Clonidine; Intrathecal; Sympathomimetic; Withdrawal