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Case Reports: Unusual presentation of more common disease/injury
Alprazolam and lorazepam overdose and the absence of brainstem reflexes
  1. Suthimon Thumtecho1,
  2. Sorawit Wainipitapong2,
  3. Sedthapong Chunamchai3 and
  4. Suchai Suteparuk1
  1. 1Division of Toxicology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
  2. 2Department of Psychiatry and Center of Excellence in Transgender Health, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
  3. 3Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
  1. Correspondence to Dr Suthimon Thumtecho; suthimon.t{at}chula.ac.th

Abstract

Benzodiazepines (BZDs) rarely cause respiratory depression and death. On the other hand, high-dose BZDs may lead to profound sedation and diminished brainstem functions that mimic other structural brain lesions as described in our case: a 70-year-old unresponsive woman. She was hypothermic and had rapid shallow breathing. Her Glasgow Coma Scale score was E1V1M4, with pinpoint pupils and absent corneal, oculocephalic and oculovestibular reflexes. Other physical exams, laboratory testing and brain imaging were unremarkable. After two doses of 0.4 mg naloxone and intravenous thrombolytics were given, there were no significant responses, and the diagnosis remained a mystery. The cause of her unconsciousness was uncovered when her husband found empty bags of 80 tablets of alprazolam and lorazepam. Her consciousness and brainstem reflexes improved dramatically after 0.25 mg of intravenous flumazenil. The blood for BZDs concentration showed alprazolam 268 ng/mL (20–40 ng/mL), lorazepam 861 ng/mL (20–250 ng/mL) and their metabolites.

  • Neurology (drugs and medicines)
  • Psychiatry (drugs and medicines)
  • Medical management
  • Drug misuse (including addiction)
  • Toxicology

https://doi.org/10.1136/bcr-2022-248796

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    Footnotes

    • Contributors The study was supervised by SS. The patient was under the care of ST. The report was written by ST, SW and SC.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.