Recurrent Episodes of Altered Mental Status with Olfactory Hallucinations in a Patient on Multiple Medications

Case at a Glance

A 40-year-old female with ADHD, anxiety, and opioid use disorder presented with acute episodes of altered mental status, olfactory hallucinations, and severe brain fog following medication adjustments and acute stress.

Patient's Story

The patient reported a 2.5-month history of stable treatment with stimulant medication (dextroamphetamine/amphetamine) for ADHD, propranolol for anxiety-related symptoms, and zolpidem for insomnia. During a period of acute family stress involving a relative's terminal illness, she experienced severe insomnia and took an additional dose of zolpidem (total 10mg). The following day, after skipping her ADHD medication, she developed sudden onset nausea, followed by an intense abnormal smell (described as burnt toast-like), tactile hallucinations (sensation of skin detaching), near-syncope, and severe cognitive impairment. Similar episodes recurred, including during air travel.

Initial Assessment

Physical examination was deferred as patient felt too unwell to seek immediate medical care. Patient reported no loss of consciousness but described severe brain fog, difficulty with speech and cognition, and overwhelming fatigue. Symptoms persisted for 48+ hours with fluctuating severity.

The Diagnostic Journey

Patient questioned whether symptoms were related to chronic zolpidem use, acute withdrawal from stimulant medication, medication interactions, or dietary indiscretion (gluten exposure despite known sensitivity). The constellation of olfactory hallucinations, altered mental status, and cognitive impairment raised concerns for seizure activity, particularly given the burnt toast-like smell often associated with temporal lobe seizures.

Final Diagnosis

Suspected complex partial seizures with post-ictal confusion, possibly precipitated by acute stress, sleep deprivation, medication changes, or underlying metabolic factors. Differential diagnosis included medication withdrawal syndrome or adverse drug reaction.

Treatment Plan

Patient planned to continue current ADHD medication regimen and monitor for symptom recurrence. Consideration for neurological evaluation including EEG and brain imaging if episodes persist. Sleep hygiene counseling and stress management strategies recommended.

Outcome and Follow-up

Patient experienced symptom recurrence during travel, reinforcing concern for seizure disorder. Long-term neurological follow-up recommended for definitive diagnosis and seizure management if confirmed. Patient education provided regarding when to seek emergency care for future episodes.