A CASE OF STATUS EPILEPTICUS SECONDARY TO BUPROPION OVERDOSE TREATED WITH IV LIPID EMULSION THERAPY

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bupropion is a norepinephrine/dopamine reuptake inhibitor useful in depression and smoking cessation, with seizures being its most well-known adverse effect. Here, we present a case of status epilepticus secondary to Bupropion overdose (OD), successfully treated with intravenous lipid emulsion (ILE) therapy. CASE PRESENTATION: A 21-year-old female with a past medical history of depression, anxiety, PTSD, and polysubstance abuse, presented to the emergency room with bizarre behavior. Her roommate reported finding empty pill bottles of bupropion, gabapentin, and propranolol at her apartment. On arrival, vitals were HR: 140, BP: 119/59, RR: 18, SpO2: 98%, and GCS: 12. Soon after, the patient had a tonic-clonic seizure that initially subsided on administering 2mg of Lorazepam. Post-seizure, she was tachycardic, diaphoretic with dry oral mucosa, and had dilated pupils with conjunctival injection. Pertinent laboratory findings included an arterial blood gas analysis suggestive of severe high anion gap metabolic acidosis secondary to elevated lactate of 13.2 mmol/L. Her urine toxicology was positive for amphetamine. Salicylates, acetaminophen, and alcohol levels were undetectable. CT head was unremarkable. She was transferred to ICU and intubated for an increasing frequency of seizures and status epilepticus. Despite being on lorazepam drip, her seizures continued and were also resistant to phenobarbital, levetiracetam, valproate, fentanyl, and propofol. Ventricular tachycardias further complicated her course with hemodynamic instability, requiring electro cardioversion and multiple vasopressors. The history of empty bottles of bupropion, positive amphetamine in urine toxicology, along with seizures and ventricular tachycardias, led to a suspicion of bupropion overdose. Intravenous lipid emulsion (ILE) therapy was administered, consequently reversing bupropion toxicity evidenced by cessation of seizures, decreasing vasopressor requirement, improvement in mental status, and extubation. DISCUSSION: Seizures, ventricular tachycardias, and QT prolongation are well-known side effects of bupropion OD, which can occur at any dose with higher incidences noted at higher doses. Positive amphetamines on urine toxicology are expected with bupropion use as their metabolites have chemical structures similar to amphetamine. Intravenous lipid emulsion therapy (ILE) was used in our patient as salvage therapy for bupropion overdose in the setting of hemodynamic instability and status epilepticus with effective reversal of toxicity. The proposed mechanism of action involves ILE sequestering lipophilic drugs such as bupropion followed by its removal via biliary excretion into the gut. However, the use of ILE lacks high-powered evidence, and further investigation is warranted to expand and strengthen the antidotal uses of ILE. CONCLUSIONS: ILE therapy can be used as an antidote for severe bupropion toxicity. REFERENCE #1: Bornstein K, Montrief T, Anwar Parris M. Successful Management of Adolescent Bupropion Overdose with Intravenous Lipid Emulsion Therapy. J Pediatr Intensive Care. 2019;8(4):242-246. doi:10.1055/s-0039-1693483 REFERENCE #2: Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014;186(13):1015. doi:10.1503/cmaj.131534 REFERENCE #3: Casey ER, Scott MG, Tang S, Mullins ME. Frequency of false positive amphetamine screens due to bupropion using the Syva EMIT II immunoassay. J Med Toxicol. 2011 Jun;7(2):105-8. doi: 10.1007/s13181-010-0131-5. PMID: 21191682; PMCID: PMC3724447. DISCLOSURES: No relevant relationships by Mubashir Ayaz Ahmed, source=Web Response No relevant relationships by Shayet Hossain Eshan, source=Web Response No relevant relationships by sami hussein, source=Web Response No relevant relationships by Sudha Misra, source=Web Response No relevant relationships by Chenyu Sun, source=Web Response