A Comatose Patient with a Bluish Tongue.

A 26-year-old Caucasian man collapsed in the morning after having drunk several glasses of beer the night before. The paramedics found him comatose with a blood pressure of 140/70 mmHg, a regular pulse of 60/min, a respiratory rate of 14/min, and a Glasgow Coma Scale of 5 (E1M3V1). The patient did not respond to verbal stimuli and appeared to have a bluish tongue. There were no focal neurologic signs, and his pupils were reactive to light and were not miotic. Blood analysis showed no abnormalities except for an alcohol concentration of 200 mg/dL. Urine analysis for benzodiazepines and opioids was negative, as well as blood analysis for paracetamol. In the absence of neurologic abnormalities, intracerebral pathology or epilepsy did not seem likely. He was admitted to the Intensive Care Unit for close neurological observation and supportive measures.To rule out an intoxication other than alcohol, relatives searched his house for medicines and drugs. An empty bottle of Rivotril® (clonazepam, liquid, 25 mg) was found that belonged to his girlfriend. No other substances were found aside from alcohol. Additional history from his relatives and friends did not reveal any other clues.Because clonazepam was the only substance suspected and because of the bluish tongue (Rivotril is a blue liquid), clonazepam intoxication was considered likely despite the negative benzodiazepine screening result. Flumazenil (Anexate®) 0.5 mg was administered as an antidote. His Glasgow Coma Scale immediately improved to 15, which strongly suggested a benzodiazepine intoxication, in this case most likely due to clonazepam. A blood sample from admission, analyzed by LC-MS/MS, proved to be positive for clonazepam with a concentration of 79 ng/mL (therapeutic range, 30–60 ng/mL). The patient recovered without any permanent damage and was discharged after 2 days.### QUESTIONS TO CONSIDER1. What …