A Comatose Patient with a Bluish Tongue

5. Dezember 2019
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A 26-year-old Caucasian man collapsed in the morning after having drunk several glasses of beer the night before.


Annelienke M. van Hulst,1† Hendrick J.W. Lammers,2 W.A.C. (Kristine) Koekkoek,3* Charlotte A. Smulders,4 and David H.T. Tjan1

Departments of 1Intensive Care; 2Hospital Pharmacy; 3Internal Medicine; 4Pediatrics, Gelderse Vallei Hospital, Ede, The Netherlands.
*Address correspondence to this author at: Willy Brandtlaan 10, 6716 RP Ede, the Netherlands. Fax +31-31-843-4116; e-mail KoekkoekK@zgv.nl

Case Description

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.

Questions to Consider

  • What are some of the limitations of urine benzodiazepine screening assays?
  • What additional testing should be performed on this patient?
  • What antidote could potentially be used in this patient?

Final Publication and Comments

The final published version with discussion and comments from the experts appears in the August 2018 issue of Clinical Chemistry, approximately 3-4 weeks after the Student Discussion is posted.