A 58-year-old male on tranylcypromine for atypical depression presents to the emergency department with a severe headache, palpitations, and elevated blood pressure (200/110 mmHg) after consuming a large amount of aged cheese and red wine at a party. Which of the following is the most likely cause of his symptoms?

Explanation

Tranylcypromine is an MAOI. MAOIs inhibit the breakdown of tyramine, an indirectly acting sympathomimetic amine found in aged cheeses, red wine, fermented foods, and certain meats. When ingested in large quantities by a patient on an MAOI, tyramine can cause a massive release of norepinephrine from sympathetic nerve endings, leading to a hypertensive crisis characterized by severe headache, palpitations, sweating, and dangerously high blood pressure. Serotonin syndrome typically involves mental status changes, autonomic hyperactivity, and neuromuscular abnormalities, often from drug-drug interactions. Neuroleptic malignant syndrome is associated with antipsychotics. Anticholinergic crisis presents with 'dry as a bone, red as a beet, hot as a hare, blind as a bat, mad as a hatter' symptoms.