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నైరూప్య

Malignant Baclofen Induced Coma Reversible by Dialysis in a 67-Year Old Patient with Acute Kidney Injury

Oliver Malle*, Tadeja Urbanic Purkart, Karin Amrein

Introduction: Baclofen is a commonly used drug for the treatment of muscular spasticity and other conditions such as pain, alcohol withdrawal and myoclonus and is contraindicated in chronic kidney disease. Eliminated predominantly by the kidneys, acute renal insufficiency can lead to acute baclofen overdose with central nervous system affection caused by accumulation. Currently, there is no consensus about the treatment of baclofen intoxication. However, several reports showed that haemodialysis can effectively clear baclofen. We report a 67-yearold patient with baclofen intoxication caused by acute kidney failure presenting in a deeply comatose state that could be completely reversed within hours after one single haemodialysis.

Case report: A 67-year-old woman was admitted with altered mental status and vomiting. Initially she was unresponsive, lethargic, with intermittent ability of nonverbal communication gradually sliding into a comatose state with apneas (Glasgow Coma Scale 5). Initial neurologic and radiologic examinations could exclude a structural lesion of the central nervous system. Laboratory data showed acute renal failure and suspected urinary tract infection with extremely high inflammatory parameters. The patient had a history of multiple sclerosis and received daily oral baclofen (3 × 25 mg daily started with a normal kidney function). Baclofen induced coma secondary to baclofen overdose caused by the renal failure was suspected and haemodialysis started within 24 hours. Cystoscopy and implantation of bilateral JJ stents was necessary because of obstructive nephropathy. During haemodialysis the patient’s mental status steadily improved. The patient woke up and was orientated and cooperative. Both clinical and laboratory data widely normalized within days.

Discussion: This report demonstrates rapid and full recovery from deep coma in a patient with baclofen overdose associated with acute renal insufficiency and delayed elimination. We assume that drug elimination was increased with haemodialysis and recovery thus accelerated. Diagnosis of baclofen overdose can be challenging, but adequate supportive therapy including haemodialysis should be considered to reduce time of comatose state and the risk of aspiration pneumonia.