Mikey had led a hard life, even though he was barely 30. His mother ran off when he was a teen, leaving him with his grandmother-and leaving his father embittered. Battered and berated by his hard-drinking dad, Mikey had little love for anyone other than grandma. When she died, he hit the road, without saying goodbye to his father. He headed north, leaving his home and the hill country behind.
He never gave thought to how much he drank, until his new girlfriend left him. He decided it was time to be a better man than his father. Besides, he had just landed a job with benefits, not a great job, but a job just the same. Detox was free, so he signed on-and stayed on for their 30 sessions of once-weekly evening rehab until his insurance stopped paying. That is when he was referred to me.
Once sober, Mikey had flashbacks about his father but could no longer blot them out with booze. The venlafaxine treatment that was started in his outpatient program helped a little, but not enough. So we upped the dose. Soon enough, he looked like a new person, with a haircut and non-crumpled clothes.
As I listened to his story, I could picture Mikey riding the rails, singing sad ballads while strumming a banjo-had he been born in the 1930s, when Steinbeck wrote. Instead, Mikey landed in Williamsburg, Brooklyn, while it was still affordable to artists. After work, he wrote short stories (inspired by Steinbeck) and published in neighborhood zines. It was just before the big Blog Boom. Someone who was SOMEONE saw his work and offered him an internship in an NYC publishing house.
Mikey found a new family at Alcoholics Anonymous (AA) and Adult Children of Alcoholics meetings. His sponsor encouraged him to take evening classes to improve his writing skills-and his self-confidence. Apparently, those efforts paid off. Mikey deserved more than his lot in life, and it looked like it could happen. Yet Mikey couldn’t believe that his luck could change. In a way, he was right.
All was going well until his eczema got infected. He had joined a gym, for the first time in his life, but the gym was a hotbed of methicillin-resistant Staphylococcus aureus (MRSA). Not to be deterred, Mikey made an appointment with a private dermatologist, thrilled that he had insurance and no longer needed to wait hours at a public clinic.
He missed our next appointment. That was a first, since he was so reliable. I called his daytime number, which turned out to be his office. The receptionist said that she had not seen him all week. Suspecting that he relapsed, I called his home. He sounded confused, unsure of the date. He said that he missed work too. He saw his primary care physician (PCP) twice that week, first for vertigo, then again after falling in a store.
He insisted that he was not drinking-or drugging-although his PCP accused him of doing just that. I believed Mikey-why would a seasoned drinker consult a doctor about hangovers? His toxicology screens from his rehab were consistently negative, and he had no history of drugs. I pressed for details. He said that he was dizzy off and on. He thought it was the flu. A day later, the room starting spinning.
He promised to ask a buddy to bring him to my office. As usual, Mikey filled out the standard form in my waiting room, completing questions about other medications taken, other doctors consulted, and new medical conditions (along with psychiatric symptoms, psychotropic medications, herbals, and alternatives). He wrote, “antibiotic-dermatologist-MRSA.”
The antibiotic was new. So was the MRSA infection. So I asked some questions. Mikey explained how his eczema got infected and that he started new medicine, but he could not recall the name. When prodded for information, he stammered, and said, “All I remember is that the pharmacist told me not to eat aged ham . . . and ripe bananas . . . and some other things that I don’t remember.” Immediately, my antennae went up. Food restrictions? Yes, for MAOIs. But for antibiotics? Maybe he was taking something else.
“Anything else that you remember?” Mikey strained, and then said, “Yeah, he mentioned something about beers and wines, but I didn’t pay attention, since I’m sober and don’t plan to drink.”
Something sounded suspicious. MAOIs have dietary restrictions and preclude the ingestion of aged beers, cheap Chiantis, and overripe cheeses, all standard fare at art gallery openings. I remembered that salami, pastrami, pickled herring, and chopped liver are verboten in patients taking MAOIs, because of their tyramine content-but old-fashioned deli favorites that carried meaning for me might not resonate with Mikey. He remembered aged ham because of his grandma’s Christmas ham-the last meal she cooked.
A psychoanalyst could have had a field day exploring the meaning behind Mikey’s scatter-shod memories. However, his neurological symptoms sounded too urgent-and too much like serotonin syndrome-to get sidetracked. Luckily, Mikey found the pharmacy phone number. I called, told the clerk that it sounded like my patient may be taking an MAOI, along with the antidepressant that I prescribed. The pharmacist picked up the phone in record time. He checked the records and announced that Mikey filled a prescription for an antibiotic that was new on the market-and, yes, linezolid is an MAOI. We agreed that Mikey’s insidious symptoms were strongly suggestive of serotonin syndrome.
I sent Mikey off to the local emergency department, where they watched him for 24 hours. I told him to stop the venlafaxine, even if it meant enduring SNRI discontinuation syndrome. Discontinuation syndrome is unpleasant but not lethal, whereas serotonin syndrome can be deadly. Mikey had never been suicidal, and he had solid support from AA friends to help him through the ordeal, so that was reassuring.
His PCP was away, but the prescribing dermatologist responded to my message immediately, even though he was away on vacation. He apologized for the shoddy phone service on his CME cruise. The dermatologist sounded worried, but he noted that there was no black box warning for linezolid and that the package insert did not mention the need for medication or food restrictions, which are necessary for “stronger” MAOIs.
He continued, “This new drug can be prescribed for outpatients. Usually, we hospitalize patients with infections like this one.” He thought he was doing Mikey a favor by keeping him home and letting him work. “No one mentioned that it’s an MAOI.” I agreed; there was nothing about the name of the antibiotic to suggest that it is an MAOI. The good news: Mikey’s skin no longer looked infected.
Mikey’s moods went up and down over the next few weeks. Yet he never returned to drinking. He also never returned to work, because he was fired for not showing up. Like his PCP, his boss presumed that he relapsed and would not offer a second chance after he gave him his big chance.
Mikey was sanguine about the events that unfolded. “Them’s the breaks,” he said, restraining his emotions. He did not seem angry about his experience with serotonin syndrome or its repercussions. Rather, he was relieved to learn that his dizziness, confusion, and loss of balance could have gotten much worse, but instead disappeared. Someone else might have become irate.
When I attempted to report his case, I learned about recent filings from the Mayo Clinic. Several patients fared far worse before the correct diagnosis was made. Some did not survive. The manufacturer has added a black box warning, alerting prescribers and pharmacists that linezolid is indeed an MAOI and that prescribing restrictions apply. In Mikey’s case, this new miracle drug was a Trojan horse.
Mikey dropped by my office to say goodbye before he left the city. It was time to hit the road again. He could not afford New York without a job, and he refused to return to bartending. As he swung his backpack over his shoulder, he said he finally felt lucky. He lost a job-but did not lose his life. I felt lucky, too, because of everything I memorized in medical school, and because my affection for chopped liver finally found its purpose: it reminded me of MAOIs. No matter how hard I tried, I could never forget chopped liver, salami, and pastrami. Likewise, Mikey never forgot his grandma’s Christmas ham.
And, for the reasons above, psychiatrists should never forget that they are physicians first-and that there may be medical reasons, as well as toxicological or psychological reasons, for loss of balance.
Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City.