Abstract
BackgroundFluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used in the treatment of depression. While most intoxications with SSRI’s have favorable outcomes and do not require interventions other than strict observation of vital signs and heart rhythm, clinicians should be aware of the life-threatening complications that may occur.Case presentationA 61-year-old woman presented to the emergency department after an intentional multiple drug overdose. Upon examination, she was somnolent with stable respiration and hemodynamics. Electrocardiography showed a prolonged QTc interval of 503 ms. The patient was admitted to the ICU for cardiopulmonary monitoring. During admission, the patient remained stable and showed improved neurologic function over time. After 22 h, a second ECG showed normalization of the QTc interval to 458 ms. However, 36 to 40 h after admission, our patient developed recurrent episodes of Torsades de Pointes (TdP) with loss of cardiac output, leading to cardiopulmonary resuscitation. Spontaneous circulation was restored after intravenous administration of magnesium sulphate. Retrospective serum analysis revealed fluoxetine concentrations of 2700 mcg/l.ConclusionMost intoxications with selective serotonin reuptake inhibitors (SSRI) have favorable outcomes and do not require medical interventions other than strict cardiopulmonary observation. However, higher doses have been associated with QTc interval prolongation, TdP, serotonin syndrome, and death. This case illustrates that life-threatening complications may occur late in the course of hospital admission. Even though overdoses with SSRI’s generally result in few fatalities, clinicians should be aware of the life-threatening clinical manifestations that may occur. Despite being an imperfect predictor of imminent TdP, continuous monitoring of cardiac rhythm is strongly recommended when either cardiac or non-cardiac symptoms are present.
Highlights
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used in the treatment of depression
Higher doses have been associated with QTc interval prolongation, Torsades de Pointes (TdP), serotonin syndrome, and death
Even though overdoses with SSRI’s generally result in few fatalities, clinicians should be aware of the life-threatening clinical manifestations that may occur
Summary
We described a case of intentional drug overdose with fluoxetine resulting in QT prolongation and the development of TdP. High-dose intoxications have been associated with QT prolongation, TdP, and eventually, death. This case illustrates that both measurement of serum drug concentrations and monitoring of the QT interval are imperfect indicators of imminent cardiac dysrhythmias. Abbreviations CYP2D6: Cytochrome P450 family 2 subfamily D member 6; ECG: Electrocardiogram; Hb: Hemoglobin; ICU: Intensive care unit; LQTS: Long QT syndrome; MCV: Mean corpuscular volume; SSRI: Selective serotonin reuptake inhibitor; TdP: Torsades de Pointes. All authors read and approved the final manuscript. Author details 1Intensive Care Unit, Deventer Hospital, Nico Bolkesteinlaan 75, Deventer 7416 SE, The Netherlands. Author details 1Intensive Care Unit, Deventer Hospital, Nico Bolkesteinlaan 75, Deventer 7416 SE, The Netherlands. 2Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, Deventer 7416 SE, The Netherlands
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