JD is a 19-year-old Caucasian male with pertinent history of insulin-dependent diabetes mellitus on an insulin pump and unconfirmed Gilbert's syndrome with no psychiatric history who presented to the emergency department with a chief complaint of nicotine withdrawal, stating "I quit vaping cold turkey yesterday." The patient stated that he had been vaping:using electronic nicotine cigarettes:with increasing frequency over 6-9 months and using it "all day," unable to quantify further, until abruptly discontinuing. Over the course of one day of acute withdrawal, he gradually developed nausea with vomiting, as well as significant anxiety, agitation, and irritability. He denied recent illness, travel, fevers, chills, abdominal pain, or diarrhea. JD revealed that as his somatic symptoms of withdrawal were intensifying, he also began to hear voices, reporting them starting at home and occurring again the night of his presentation. Medical history included one prior uneventful hospitalization for diabetic ketoacidosis (DKA) within a few years. The patient also had a history of probable Gilbert's disease, without genetic testing confirmation, diagnosed by an outpatient gastroenterologist during a visit with thorough examination and testing:including physical examination, abdominal ultrasound, C-reactive protein, and additional labs to rule out hemolysis:that were within normal limits with the exception of showing a consistent trend of elevated bilirubin. Further substance use included marijuana vaping; however, he discontinued this one week prior to presentation with no emergence of symptoms consistent with that timeline or any previous periods of sobriety he disclosed, and he denied any illicit drug use. JD's only prescribed medication at home was his insulin aspart pump. At the time of evaluation, JD had finished his first year of college including playing on the football team.
On examination, the patient was agitated with diaphoresis but otherwise well-appearing of athletic build, well-groomed, and with appropriate hygiene. Vital assessments were stable, and he was consistently afebrile, normotensive, and with adequate oxygen saturation. Physical exam was unremarkable for head/eyes/ears/nose/throat, neck, and cardiovascular, respiratory, gastrointestinal, musculoskeletal, and neurological systems. Lab results showed anion gap metabolic acidosis (venous pH 7.30, pCO2 48, PO2 51, HCO3 23, anion gap 20, and CO2 23) with ketones in urine and blood and beta-hydroxybutyrate elevated at 3.73 but normal blood glucose (122) and lactate (1.3). JD also displayed leukocytosis with white blood cells over 15,000, as well as hyperbilirubinemia with initial bilirubin 4.9 and indirect bilirubin also elevated (3.6). Eight-panel urine drug screen was positive for THC only, with serum alcohol < 0.01. Otherwise, blood tests including lactate and TSH, as well as amylase, lipase, electrolytes, liver enzymes, C-reactive protein, calcium, magnesium, and phosphate, were unremarkable. Blood cultures were drawn and negative x2 days; otherwise, no infectious disease panels were performed. Imaging included CT of the abdomen and pelvis which was negative for any acute process such as abdominal infection. No imaging of the head or other specialized neurological testing such as EEG was performed. JD was initially treated for euglycemic DKA with 1 L bolus of normal saline, followed by D5 normal saline with insulin drip and admission to the intensive care unit.
The psychiatry team was consulted to evaluate JD's agitated behaviors and psychotic symptoms. He reported that the voices began several hours after discontinuing vaping and continued into the evening in the hospital despite ongoing otherwise effective treatment for his ketoacidosis. Although formal assessment (e.g., MoCA and MMSE) was not performed at the time, JD remained alert and oriented, appearing at his cognitive baseline during the course of these symptoms, as confirmed by his mother present at bedside and overnight nursing staff. For nicotine withdrawal, he had initially declined nicotine replacement but on his second day requested a patch. Notably, his experience of voices began to subside after agreeing to initiate a nicotine patch that morning. The hallucinations resolved within a day. He denied any recent mood symptoms beyond his irritability following discontinuation of vaping and denied any history of hallucinations outside of the recent events, even during his previous hospitalization for DKA. Throughout the 3-day course of admission and treatment for his metabolic acidosis following the standard DKA protocol, his overall condition improved, with repeat labs showing a trend toward normalization and clearance by the endocrinology team for discharge home. His insulin pump was examined and did not require adjustment. He was not started on any psychotropic medications, though he was provided with information to pursue outpatient therapy for nicotine/substance use and school-related stressors.
Four months later, JD returned to the hospital with worsening nausea and vomiting over the course of one day in the absence of recent travel or other symptoms beyond some nasal congestion. At the time, he revealed that he had resumed use of e-cigarettes after his last hospitalization, with the most recent use just prior to presentation. He was again treated for euglycemic DKA after being found to have elevated urine ketones, serum beta-hydroxybutyrate (1.31), and anion gap 14 with normal glucose (108) and lactate (1.0). Bilirubin was also elevated at 4.2. Abdominal series showed no acute process, and abdominal ultrasound demonstrated thick bile sludge without stones but was otherwise normal. The remaining labs were unremarkable as well. A drug screen was not performed at that time, though he did report continued marijuana use. The treatment course followed the same trajectory as his prior hospitalization, with the exception that a nicotine replacement patch was applied earlier on in this episode, at the time of admission. With this presentation being otherwise the same as his last with the notable difference being that he did not experience nicotine withdrawal, remarkably, he also did not exhibit or describe any associated irritability or hallucinations during this hospitalization.