How to manage a 19-year-old male with bilateral tinnitus, taking Remicade (Infliximab) and Hydroxyzine, presenting with tachycardia and hypotension?

Management of Bilateral Tinnitus in a 19-Year-Old Male with Tachycardia and Hypotension

The 19-year-old male with bilateral tinnitus, tachycardia, and hypotension requires immediate evaluation for medication-related adverse effects from Remicade (infliximab), with fluid resuscitation as the first intervention to address hypotension. 1, 2

Initial Assessment and Stabilization

1. Address Hemodynamic Instability First

   • Vital signs show tachycardia (101 bpm) and hypotension (96/74 mmHg)
   • Start IV fluid resuscitation with normal saline bolus (500-1000 mL)
   • Monitor vital signs every 15 minutes until stabilized

2. Medication Review

   • Remicade (Infliximab): Known to cause infusion reactions and hypersensitivity reactions that can manifest as tinnitus, tachycardia, and hypotension 1
   • Hydroxyzine: Can cause anticholinergic effects but unlikely to be the primary cause of current symptoms

Diagnostic Workup

1. Immediate Laboratory Tests

   • Complete blood count to assess for infection or anemia
   • Basic metabolic panel to evaluate electrolyte abnormalities
   • Inflammatory markers (ESR, CRP) to assess for underlying inflammatory process
   • Cardiac enzymes if chest pain is present

2. Audiologic Evaluation

   • Schedule comprehensive audiologic testing as bilateral tinnitus may indicate hearing loss 2, 3
   • Assess for asymmetry in tinnitus symptoms (patient reports left ear dominance)

3. Imaging Studies

   • If tinnitus persists after stabilization and is unilateral/asymmetric, consider MRI of the brain with contrast to rule out vestibular schwannoma or other intracranial pathology 2, 3

Management Plan

1. For Hypotension and Tachycardia

   • IV fluid resuscitation as first-line treatment
   • If hypotension persists despite adequate fluid resuscitation, consider:
     • Temporary discontinuation of Remicade
     • Consultation with rheumatologist regarding medication management

2. For Tinnitus

   • If related to Remicade infusion reaction:
     • Consider antihistamines (patient already on hydroxyzine)
     • Consider corticosteroids if symptoms are severe
   • If tinnitus persists after stabilization:
     • Sound therapy (white noise, nature sounds)
     • Cognitive behavioral therapy for persistent symptoms 3, 4

3. Medication Adjustments

   • Remicade: Consider temporary discontinuation if symptoms are determined to be an infusion reaction or delayed hypersensitivity reaction 1
   • Hydroxyzine: Continue as it may help with potential histamine-mediated symptoms

Follow-up Plan

1. Short-term Follow-up (1 week)

   • Reassess vital signs and tinnitus symptoms
   • Review laboratory results
   • Discuss audiologic evaluation findings

2. Long-term Management

   • If Remicade is determined to be the cause:
     • Consider premedication with antihistamines and corticosteroids before future infusions
     • Discuss alternative biologic agents with rheumatologist
   • For persistent tinnitus:
     • Hearing aids if hearing loss is identified
     • Continued sound therapy and counseling 4

Important Considerations

• Infliximab-Related Reactions: Infusion reactions can occur during or within 1 hour after infusion, but delayed hypersensitivity reactions can occur 3-12 days after administration 1
• Tinnitus Classification: Determine if tinnitus is pulsatile or non-pulsatile, as pulsatile tinnitus may indicate vascular abnormalities requiring different management 2
• Avoid: Unnecessary imaging if tinnitus is bilateral, non-pulsatile, and not associated with asymmetric hearing loss or focal neurologic abnormalities 2, 3

Remember that tinnitus is a symptom, not a disease, and addressing the underlying cause (likely medication-related in this case) is crucial for effective management 5, 6.