More is never better when patients exceed recommended dosages, but a 62-year-old woman with schizophrenia took self-medication to an extreme that might have proved fatal. She presented with acute-onset chest tightness and dyspnea after taking 40 docusate tablets, 100 mg, for constipation. Subsequently, she developed voluminous diarrhea, which precipitated progressive shortness of breath and angina.
The patient had a blood pressure of 60/35 mm Hg and a heart rate of 110 beats per minute. She had bibasilar rales and a 3/6 harsh precordial pansystolic murmur. An electrocardiogram (ECG) showed new 2-mm ST-segment elevation in the aVR lead and 2-3 mm ST segment depressions in the inferolateral leads. The blood urea nitrogen and creatinine levels were dramatically elevated from her normal baseline, though the ratio, measuring 79 mg/dL:7.9 mg/dL or 10:1, was normal, as was her troponin T level.
Ten liters of normal saline were administered over several hours, but the patient’s blood pressure remained low at 85/45 mm Hg, and her symptoms worsened. She was oliguric with continuing bibasilar rales. Pulmonary edema was evident on a chest x-ray. A prior transthoracic echocardiogram showed moderate asymmetric septal hypertrophy (18 mm), anomalous papillary muscle insertion into the anterior mitral valve leaflet without intervening chordae, and a left ventricular outflow tract gradient of 20 mm Hg at rest and 26 mm Hg when standing; the last 2 were signs of hypertrophic cardiomyopathy.
The patient’s presumptive diagnosis was heart failure and shock resulting from severe augmentation of left ventricular outflow obstruction in hypertrophic cardiomyopathy. While hypovolemic shock is common after profuse diarrhea, cardiogenic shock with pulmonary edema is not. Cardiogenic shock precipitated by stool-softener abuse has not been reported.
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– Tiberio M. Frisoli, MD, Daniel G. Swistel, MD, Harikrishna Makani, MD, Mark V. Sherrid, MD
This article originally appeared in the September 2013 issue of The American Journal of Medicine.
