Lorazepam

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 72-year-old man exhibited lack of efficacy while receiving lorazepam for tremors [dosage not stated].

The man, who had a history of gastroesophageal reflux disease and hyperlipidemia, presented to the emergency department with severe tremors for 3 days which were worsened. Two day previously, he had developed fever. He was positive for SARS-CoV-2 and diagnosed with COVID-19. He received IV lorazepam without improvement. Subsequently, he admitted to the general medical floor. Neurology consultants considered his abnormal motor changes were due to multifocal myoclonus. He treated with IV lorazepam. His clinical status quickly worsened. On hospital day 2, he was transferred to the ICU with violent, sinus tachycardia, whole body tremors, altered mental status and hyperpyrexia. Inducible clonus and severe rigidity were noted. Despite IV bolus lorazepam, he required intubation. He was empirically treated with broad spectrum antibiotics. He qualified Hunter and Sternbach Criteria. Consequently, cyproheptadine was started. His comprehensive medication were reviewed, but did not revealed potentially offending serotonergic medicines. He was treated with corticosteroids for COVID−19. Within 24 hours, the fever resolved. He continued on propofol infusion with scheduled cyproheptadine. Neurologic abnormalities were decreased. However, on sedation holidays neurologic abnormalities returned to lesser degree. On intubation day 3, EEG showed slowed rhythm. On mechanical ventilation day 4, he was extubated. Mild intention tremor and truncal ataxia were noted. The weakness and ataxia resolved with physical therapy. The tremor resolved before discharge. On hospital day 11, he was discharge to a rehabilitation facility.