When drugs cause a life-threatening reaction

A mos* was in his second year of campus studying for a bachelor’s degree in Tourism when he was taken ill. He developed a headache, chills and fevers in a short span of six hours and before he knew it, he was admitted at the university clinic.

Through the night, instead of getting better, Amos’s condition only seemed to worsen. He was vomiting repeatedly and could not seem to keep anything down. His joints and muscles decided to join the arsenal of anatomical organs that seemed to be infatuated with the idea of torturing him.

He was given fluids throughout the night and medication to help stop the vomiting and manage the fever and by morning, he was referred to the hospital for proper diagnosis and treatment. His parents were also informed and they met the ambulance at the emergency department.

Amos was received at the emergency department quite sick. His fevers were spiking and he was now developing jaundice. Following tests, he was diagnosed with severe malaria, hooked onto a quinine drip and transferred to the wards for continued care.

I met Amos the next morning during the ward rounds. He certainly looked sick. He was lying listlessly in bed nursing his headache, while his quinine drip was running. The nurse came by to give him his pain medications and an intravenous shot of metochlopramide to control his vomiting. His mum was patiently feeding him porridge in small spoonfuls as he had not eaten anything the past two days. Amos had never suffered malaria before and the events going on in his body and around him were quite perplexing. Thankfully, he was responding well to quinine and hopefully if he could manage to eat up, he could go home in a few days on oral medication.

By his second day in the wards, Amos could sit up in bed with support and much to his mum’s relief, he managed to eat a bit of solid food. He could finally take in his surroundings, appreciating the ward around him and how truly busy it was. He had never been admitted before and the idea of being in a room full of extremely sick people intimidated him quite a bit. He was determined to go home as fast as possible.

In medical school, the internal medicine rotation was one of those intense learning experiences and the ward rounds were quite exciting. There was something new to learn every day. The rounds lasted for hours as we each presented our patients and got hammered with a bunch of questions by the senior physicians, opening room for discussions and learning. We not only had to know our patients but also read extensively around their conditions.

The next morning, most of my patients were improving and were soon to be discharged. With Amos being one of my allocated patients, I felt confident that I had gone over everything possible with malaria and was ready for the discussions. My patient’s files were in order, the latest laboratory and radiology reports had been filed and the treatment sheets were at hand for reference during the round.

The rounds started promptly at nine and we started off with the most acutely ill patients. As we were going on, I felt a tug on my arm, only to turn around and find Amos’s mother looking rather distressed. She told me that Amos was not looking good. She had just arrived from home with a hot meal for him and found him exhibiting bizarre behaviour which got her very concerned. I stepped away and went with her to check on him.

I found Amos on his bed looking weird. He was in an abnormal posture on the bed, with a stiff neck turned to the side, his back arched and arms stiffly stretched out. That was not all. His eyes were rolling back involuntarily and any attempt he made to speak lead to his tongue stiffly protruding to the side. I had absolutely no idea what was happening to Amos. He certainly looked weird but it didn’t quite look like he was having a convulsion. He looked alert despite the weird contortion.

I did not know what to do, so I simply disrupted the ongoing ward round and asked for help. The team came over, led by the consultant physician, who took a moment to examine him. While we stood around gawking like the clueless students we were, the physician asked the mum a bunch of questions. The patient on the next bed also quipped that Amos had had similar episodes twice before, at night and early in the morning.

The consultant asked me for Amos’ treatment sheet and looked through it. He then asked me how long Amos had been getting metochlopramide. My confused brain still did not get it. He asked me to read about it in preparation for the next day’s rounds. He stopped the medication and prescribed an antidote to help relieve Amos’ symptoms.

Going back to my pharmacology books certainly made me wiser! We had no google back then and a quick look-up literally meant going back to my text books. I looked up metochlopramide and the side effects perfectly described Amos! He was suffering from extrapyramidal side effects of metochlopramide.

These side effects are triggered by a group of drugs known as centrally-acting dopamine receptor blockers; of which metochlopramide is one of them. Metochlopramide is a drug that prevents vomiting, quite commonly used as an injection and as a tablet. Other medications in this group are antipsychotic medications, used to treat mental illnesses.

The side effects manifest as involuntary muscle contractions that cause abnormal posture and/or repetitive movements. The muscle contractions involve the back, arms, legs, face, tongue, neck, jaw, eyes, abdomen and pelvis. This typically described what Amos was going through. It may also result in akathisia, a condition where the patient experiences involuntary movements with difficulty staying still. It is therefore easy to understand why patients struggling with such side effects will easily abandon treatment once they realise it was the trigger for these symptoms.

In severe cases, the involuntary muscle contractions can be serious enough to cause complications. These include breakdown of muscle cells, fever, increased heart rate, fast breathing, hypertensive crisis, difficulty swallowing, respiratory failure and suicidal thoughts.  Thankfully, Amos did well and his symptoms greatly improved with intervention. He was good and ready to bounce out of the ward and go back to his campus life!

Dr Bosire is an obstetrician/ gynaecologist