Attending ICU Physician Parkview Health, United States
Introduction: Alcohol withdrawal symptoms can mask the effects of other toxins in the body, especially when ingested simultaneously and can bias the clinician into not considering other possibilities. The presence of neurologic symptoms in alcohol withdrawal including visual hallucinations, confusion and delirium tremens make it difficult to detect early neurotoxicity from other substances.
Description: A 63-year-old male with a history of HIV on HART and chronic hyponatremia due to primary polydipsia was admitted to the MICU for alcohol withdrawal and sepsis secondary to pneumonia. He initially presented with confusion, delirium, tremors, agitation, restlessness and fevers – typical symptoms of alcohol withdrawal and was treated with benzodiazepines, thiamine, folic acid and broad-spectrum antibiotics. At day 5, his neurologic symptoms were expected to subside, but continued to persist. At day 7, patient had severe altered mental status and was intubated due to concerns of maintaining airway. His LFTs and creatinine continued to rise. He developed acute renal failure needing hemodialysis, ischemic hepatitis, severe sepsis and an AG metabolic acidosis. Extensive work-up including blood and sputum cultures, lumbar puncture, EEG were all negative. MRI brain showed diffuse encephalopathic changes. Upon obtaining collateral history from family, it was discovered the patient had accidentally ingested bug spray believing it to be hand sanitizer, which contains DEET, as well as a whole tube of ivermectin after he tested positive for Covid-19 one-week prior to presentation. Patient’s mental status did not improve and he did not pass spontaneous breathing trials while holding sedation. Family changed to comfort care only and patient was terminally extubated. Conferring with the state’s toxicology department, his encephalopathy, hepatic and renal failure were attributed to toxicity from DEET and ivermectin.
Discussion: Ivermectin and DEET toxicity can initially present with confusion and delirium, symptoms that overlap in alcohol withdrawal. This case aims to raise awareness for clinicians to keep their minds open when a patient presents with typical alcohol withdrawal symptoms and to further investigate other possible etiologies, especially with lab work that does not fit the patient’s medical history.
