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Coma, myalagia and hypoxia.

Accepted 27 September 1995 A 32-year-old man who had recently commenced oral methadone presented semiconscious, after a two-day history of myalgias, weakness and dyspnoea. On examination, he was drowsy, localising to pain, eye opening to speech and verbalising to pain. He had a respiratory rate of 10 min, a blood pressure of 135/80 mmHg and was febrile (38.1 C). There was tenderness over proximal muscle groups with marked muscle weakness of his legs and arms. Laboratory findings are presented in box 1. He was given supplemental oxygen, intravenous hydration with alkaline diuresis and antibiotics. His conscious state improved rapidly after intravenous naloxone. Over the next few days his hypoxia resolved, conscious state returned to normal, urine output and hydration remained stable. His muscle pains resolved and the muscle weakness greatly improved. He then complained of a painful, swollen right arm that was warm, tender and oedematous on examination.