by
Akriti G. Jain, MD, Hammad Zafar, MD, Sanjay Jain, MD, and Jason D’Souza, MD
A 56-year-old man with schizoaffective
disorder, type 2 diabetes mellitus, and no cardiac history was sent from a
psychiatric facility for evaluation of a left foot wound. He was disoriented to
time, place, and person. The patient’s core body temperature was 87.4 °F, and
his pupils were equally reactive to light. His left foot had an ulcer with a
dirty base and much foreign material, and his 2nd and 3rd toes were black with
clear demarcation. Laboratory results included a normal white blood cell count
(8 ×109/L, 23% band
neutrophils), a hemoglobin level of 7.4 g/dL, normal electrolyte levels except
for calcium elevation (11.8 mg/dL; 12.8 mg/dL after correction for albumin),
and no detected cardiac troponin. Urine toxicology results were positive for
tricyclic antidepressants (TCAs). An electrocardiogram (ECG) showed junctional
rhythm with J waves (Osborn waves); a corrected QT interval (QTc) of 468 ms; a
PR interval of 188 ms; and a heart rate of 60 beats/min (Fig. 1).
