The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 14

Case Study
by Greg Cox; Rani H. Lindberg, MD 1
1
Associate Professor, Department of Physical Medicine and Rehabilitation, UAMS, Little Rock, Ark.
Unrecognized Baclofen Withdrawal Secondary to
Inaccurate Medication Reconciliation in a Spinal Cord
Injury Patient with an Intrathecal Baclofen Pump
Abstract
Baclofen therapy is often utilized to treat spasticity
in patients that have suffered neurologic insult. In
this case, a 39-year-old man with spastic quadriplegia
presented with fever, abdominal pain, nausea,
and hematemesis 24 hours after intrathecal
baclofen (ITB) pump replacement. Initial work-up
was negative, and ITB pump was confirmed to be
functioning properly. Later, it was discovered that
the patient had been taking oral and intrathecal
baclofen, and was in acute baclofen withdrawal.
Baclofen withdrawal has a non-specific array of
symptoms and can easily be misdiagnosed. Review
of dosing habits can prevent adverse drug
events and prolonged hospitalizations.
Case Diagnosis
A 39-year-old man with spastic quadriplegia
secondary to complete spinal cord
injury presented to the emergency department
(ED) 24 hours after intrathecal
baclofen (ITB) pump replacement with
complaints of fever, abdominal pain, nausea,
and coffee ground emesis. Routine
work up for infection and abdominal pain
was notable for a urinary tract infection
(UTI) and bowel impaction. Due to the
severity of symptoms, he was admitted
and started on empiric antibiotics. Despite
treatment with antibiotics, his fever,
hypertension, and tachycardia did not
improve. The surgical site was evaluated,
and no wound infection or surgical complication
was found. The patient then underwent
bowel disimpaction for suspected
autonomic dysreflexia, but this also failed
to alleviate his symptoms. Within 24 hours of admission,
he had developed mental status changes
with hallucinations. The Physical Medicine and
Rehabilitation team was consulted to interrogate
the ITB pump for possible pump malfunction,
and it was found to be functioning appropriately.
On review of the patient’s medication list, it was
noted that he had an outpatient prescription for
oral baclofen as needed (PRN). The outpatient
ITB pump clinic notes were then reviewed, and
it was discovered the patient had been taking oral
baclofen scheduled rather than intermittently. Because
his outpatient prescription for oral baclofen
had been documented as PRN, oral baclofen was
not scheduled during his admission for ITB pump
replacement, nor had it been administered during
this readmission. Oral baclofen therapy was reinitiated,
and within 12 hours patient had resolution
of cognitive impairments and significant improvement
in spasticity, blood pressures, and heart rate
Figure 1. Baclofen pump catheter entering the spinal canal
at L3- 4 level and terminating at the T6-7 level without
discontinuity or kinking.
confirming that a significant contribution to his
presenting symptoms was baclofen withdrawal.
Discussion
We present a case of unrecognized baclofen withdrawal
resulting in a complicated post-operative
course and prolonged hospital stay. Baclofen is
commonly used for the treatment of spasticity. It
is a GABA-B receptor agonist in the central nervous
system, and achieves its therapeutic effect
via prevention of calcium influx in presynaptic
neurons, which reduces presynaptic neurotransmitter
release.4 It has been shown to improve
spasticity in 70-96% of patients. 4 Baclofen is administered
either orally or intrathecally. Administration
of baclofen intrathecally has been found to
be effective for patients with spasticity that is not
well-controlled with the maximum dose of oral
baclofen therapy. Intrathecal baclofen therapy allows
for higher concentrations of drug in the cerebrospinal
fluid than can be achieved
with oral baclofen therapy. 6
Withdrawal from baclofen can be
a life-threatening condition and
has a wide variety of signs and
symptoms such as high fever, pruritis,
sedation, weakness, altered
mental status, rebound spasticity,
and muscle rigidity. 2 Baclofen
withdrawal may be treated with IV
hydration, administration of oral or
intrathecal baclofen, or even dantrolene
and IV benzodiazepines. 7
The consequences of untreated
baclofen withdrawal are severe
and have been seen to progress
to rhabdomyolysis, neuroleptic
malignant syndrome, disseminated
intravascular coagulation, 3 multi-organ
system failure, and death. 8 Due to
the non-specific sequelae associated
with baclofen withdrawal, work-up for a different
cause is often sought. There are case reports of
baclofen withdrawal initially being misinterpreted
as sepsis, myocardial infarction, and pulmonary
embolism due to the often-complicated presentation
of acute baclofen withdrawal. 8,9
278 • The Journal of the Arkansas Medical Society www.ArkMed.org