Case of Acute Encephalopathy Associated with Montelukast
Department
Medical Education
Graduate Level
Doctoral
Graduate Program/Concentration
Eastern Virginia Medical School - Doctor of Medicine
Presentation Type
Poster Presentation
Abstract
Introduction:
Montelukast is a leukotriene receptor antagonist that is sometimes used off-label to treat chronic obstructive pulmonary disease (COPD). Although many studies have explored possible associations between montelukast and neuropsychiatric adverse events including mood disorders, suicidality, and anxiety disorders; few have investigated a specific association between montelukast and acute encephalopathy in the hospital setting.
Case:
A 59-year-old female with an extensive medical history including morbid obesity, diabetes, chronic pain, and COPD presented to the emergency department with worsening back pain, right leg pain, and paresthesias. Magnetic resonance imaging revealed spinal osteomyelitis with psoas abscess and epidural abscess. The patient was admitted and underwent drainage of the psoas abscess on hospital day 3. She was placed on long-term antibiotics for epidural abscess and bacteremia.
On hospital day 19, she had new onset of encephalopathy with fluctuating confusion, hallucinations, and speech difficulties. At that time, no severe derangements were noted on complete blood count or comprehensive metabolic panel. Serum levels of thiamine, folate, cobalamin, methylmalonic acid, copper, zinc, and thyrotropin were unrevealing. Computed tomography of the head showed no acute findings, and urine culture yielded no growth. Her encephalopathy was thought to be multifactorial in the setting of prolonged hospital stay, treatment for bacteremia and epidural abscess, and possible drug-related toxicity. The patient’s baclofen dosage was decreased from 20 mg to 10 mg three times daily; however, her mental status continued to fluctuate during the next few weeks.
On hospital day 41, her home dose of 10 mg montelukast was held to assess any impact on her mental status. Over the next few days, her mentation improved. She was able to communicate clearly, and no further episodes of agitation were reported by nursing staff. Consequently, the decision was made to discontinue the montelukast on hospital day 48. The improvement in her cognition was sustained even though other medical factors continued to fluctuate.
Discussion:
Encephalopathy is a term that describes the clinical syndrome of altered mental status resulting from brain dysfunction. The causes of acute encephalopathy are numerous and include both systemic and primary neurologic conditions. In the case of our patient, there were many factors, including medications, medical conditions, and length of hospital stay, that may have contributed to her encephalopathy. However, the temporal relationship between cessation of montelukast and improvement of her mentation suggests a possible association between this medication and the patient’s symptoms.
The United States Food and Drug Administration issued a safety advisory in 2008 and a boxed warning in 2020 due to reports of neuropsychiatric adverse events in patients taking montelukast, and many studies over the past 15 years have investigated this association. Some have suggested that montelukast is linked to mood, anxiety, and sleep disorders, and that this association may be greater in children than in adults.
Conclusion:
In this case report, we present a hospitalized patient with acute encephalopathy whose mentation improved after discontinuation of montelukast. Further research is needed to explore the potential association between montelukast and acute encephalopathy, particularly in adults.
Keywords
Encephalopathy, Neuropsychiatric, leukotriene receptor antagonist
Case of Acute Encephalopathy Associated with Montelukast
Introduction:
Montelukast is a leukotriene receptor antagonist that is sometimes used off-label to treat chronic obstructive pulmonary disease (COPD). Although many studies have explored possible associations between montelukast and neuropsychiatric adverse events including mood disorders, suicidality, and anxiety disorders; few have investigated a specific association between montelukast and acute encephalopathy in the hospital setting.
Case:
A 59-year-old female with an extensive medical history including morbid obesity, diabetes, chronic pain, and COPD presented to the emergency department with worsening back pain, right leg pain, and paresthesias. Magnetic resonance imaging revealed spinal osteomyelitis with psoas abscess and epidural abscess. The patient was admitted and underwent drainage of the psoas abscess on hospital day 3. She was placed on long-term antibiotics for epidural abscess and bacteremia.
On hospital day 19, she had new onset of encephalopathy with fluctuating confusion, hallucinations, and speech difficulties. At that time, no severe derangements were noted on complete blood count or comprehensive metabolic panel. Serum levels of thiamine, folate, cobalamin, methylmalonic acid, copper, zinc, and thyrotropin were unrevealing. Computed tomography of the head showed no acute findings, and urine culture yielded no growth. Her encephalopathy was thought to be multifactorial in the setting of prolonged hospital stay, treatment for bacteremia and epidural abscess, and possible drug-related toxicity. The patient’s baclofen dosage was decreased from 20 mg to 10 mg three times daily; however, her mental status continued to fluctuate during the next few weeks.
On hospital day 41, her home dose of 10 mg montelukast was held to assess any impact on her mental status. Over the next few days, her mentation improved. She was able to communicate clearly, and no further episodes of agitation were reported by nursing staff. Consequently, the decision was made to discontinue the montelukast on hospital day 48. The improvement in her cognition was sustained even though other medical factors continued to fluctuate.
Discussion:
Encephalopathy is a term that describes the clinical syndrome of altered mental status resulting from brain dysfunction. The causes of acute encephalopathy are numerous and include both systemic and primary neurologic conditions. In the case of our patient, there were many factors, including medications, medical conditions, and length of hospital stay, that may have contributed to her encephalopathy. However, the temporal relationship between cessation of montelukast and improvement of her mentation suggests a possible association between this medication and the patient’s symptoms.
The United States Food and Drug Administration issued a safety advisory in 2008 and a boxed warning in 2020 due to reports of neuropsychiatric adverse events in patients taking montelukast, and many studies over the past 15 years have investigated this association. Some have suggested that montelukast is linked to mood, anxiety, and sleep disorders, and that this association may be greater in children than in adults.
Conclusion:
In this case report, we present a hospitalized patient with acute encephalopathy whose mentation improved after discontinuation of montelukast. Further research is needed to explore the potential association between montelukast and acute encephalopathy, particularly in adults.