PAROXETINE OVERDOSE LEADING TO SEROTONIN SYNDROME

Abstract

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed agents because of their safety and favorable side effect profile over tricyclic antidepressants (TCAs) for neurobehavioral illnesses. Serotonin syndrome remains a rare but serious complication of SSRIs use. Although citalopram has a higher toxicity than fluoxetine, fluvoxamine, sertraline, and paroxetine1 other SSRIs can also lead to serotonin syndrome.CASE PRESENTATION: 18 years old male patient with past medical history of Delayed bone growth, Depression on paroxetine, Amphetamine, and opioid abuse was brought to the hospital after an intentional intake of a total of 420mg of paroxetine with severe agitation.He was unable to stop moving his arms. Over the period of the next six hours, the patient got very agitated and confused. Physical examination was significant for tachycardia (HR-106/min), hypertension (BP-187/125 mm hg), tachypnea (RR-20/min), and hyperthermia (38.2 C) with positive hyperreflexia (clonus) in lower extremities. His lab results were normal except for mildly raised creatinine kinase and drug test positive for opiate, cocaine, and amphetamine.His symptoms were determined to be from serotonin syndrome after excluding other potential causes.The patient was aggressively hydrated with intravenous fluids and was started high and frequent dosing of diazepam(20mg every 20minutes) initially and then switched to lorazepam. We had to intubate him for airway protection Patient was also started on cyproheptadine 12 mg/day. He was extubated after 3 days when his mental status and agitation improved. He was eventually discharged home.DISCUSSION: Serotonin syndrome is diagnosed based on features of autonomic instability, neuromuscular signs, and cognitive-behavioral changes in the presence of serotonergic medication use. Hunter's criteria2 are used to diagnose serotonin syndrome. This condition has been mostly associated with the use of monoamine oxidases and TCAs. SSRIs have been an infrequent cause of serotonin syndrome3. In our case, it was caused by paroxetine use.CONCLUSIONS: Serotonin syndrome has a favorable prognosis if recognized early and treated appropriately. Physicians must be aware of the serotonin syndrome diagnosis in patients who are on SSRIs. Serotonergic agents should be stopped and patients should be started on supportive measures in case of unclear diagnosis of serotonin syndrome because the diagnosis of serotonin syndrome is mostly clinical.Reference #1: Hawton K, Bergen H, Simkin S, et al. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. The British Journal of Psychiatry. 2010;196(5):354-358.Reference #2: Dunkley E, Isbister G, Sibbritt D, Dawson A, Whyte I. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. Qjm. 2003;96(9):635-642.Reference #3: Canan F, Korkmaz U, Kocer E, Onder E, Yildirim S, Ataoglu A. Serotonin syndrome with paroxetine overdose: a case report. Primary Care Companion to the Journal of Clinical Psychiatry. 2008;10(2):165.DISCLOSURES: No relevant relationships by Anupam SharmaNo relevant relationships by Gursimran pal ShergillNo relevant relationships by Muhammad Moiz Tahir SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed agents because of their safety and favorable side effect profile over tricyclic antidepressants (TCAs) for neurobehavioral illnesses. Serotonin syndrome remains a rare but serious complication of SSRIs use. Although citalopram has a higher toxicity than fluoxetine, fluvoxamine, sertraline, and paroxetine1 other SSRIs can also lead to serotonin syndrome. CASE PRESENTATION: 18 years old male patient with past medical history of Delayed bone growth, Depression on paroxetine, Amphetamine, and opioid abuse was brought to the hospital after an intentional intake of a total of 420mg of paroxetine with severe agitation. He was unable to stop moving his arms. Over the period of the next six hours, the patient got very agitated and confused. Physical examination was significant for tachycardia (HR-106/min), hypertension (BP-187/125 mm hg), tachypnea (RR-20/min), and hyperthermia (38.2 C) with positive hyperreflexia (clonus) in lower extremities. His lab results were normal except for mildly raised creatinine kinase and drug test positive for opiate, cocaine, and amphetamine. His symptoms were determined to be from serotonin syndrome after excluding other potential causes. The patient was aggressively hydrated with intravenous fluids and was started high and frequent dosing of diazepam(20mg every 20minutes) initially and then switched to lorazepam. We had to intubate him for airway protection Patient was also started on cyproheptadine 12 mg/day. He was extubated after 3 days when his mental status and agitation improved. He was eventually discharged home. DISCUSSION: Serotonin syndrome is diagnosed based on features of autonomic instability, neuromuscular signs, and cognitive-behavioral changes in the presence of serotonergic medication use. Hunter's criteria2 are used to diagnose serotonin syndrome. This condition has been mostly associated with the use of monoamine oxidases and TCAs. SSRIs have been an infrequent cause of serotonin syndrome3. In our case, it was caused by paroxetine use. CONCLUSIONS: Serotonin syndrome has a favorable prognosis if recognized early and treated appropriately. Physicians must be aware of the serotonin syndrome diagnosis in patients who are on SSRIs. Serotonergic agents should be stopped and patients should be started on supportive measures in case of unclear diagnosis of serotonin syndrome because the diagnosis of serotonin syndrome is mostly clinical. Reference #1: Hawton K, Bergen H, Simkin S, et al. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. The British Journal of Psychiatry. 2010;196(5):354-358. Reference #2: Dunkley E, Isbister G, Sibbritt D, Dawson A, Whyte I. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. Qjm. 2003;96(9):635-642. Reference #3: Canan F, Korkmaz U, Kocer E, Onder E, Yildirim S, Ataoglu A. Serotonin syndrome with paroxetine overdose: a case report. Primary Care Companion to the Journal of Clinical Psychiatry. 2008;10(2):165. DISCLOSURES: No relevant relationships by Anupam Sharma No relevant relationships by Gursimran pal Shergill No relevant relationships by Muhammad Moiz Tahir