PROLONGED LYSERGIC ACID DIETHYLMIDE INDUCED SEROTONIN SYNDROME

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Serotonin syndrome (SS) is a life threatening condition which may often be difficult to diagnose. The increasing incidence of SS is attributable to the wide use of selective serotonin reuptake inhibitors, opioids, and recreational drugs like Lysergic Acid Diethlymide (LSD) which act primarily through 5-HT2 serotonin receptors1. Severe cases often require aggressive intervention in the Intensive Care Unit (ICU) to manage hyperthermia, ventilation, seizures, delirium, rhabdomyolysis, and autonomic instability; however, frequently used analgesics in the ICU such as Fentanyl also contribute to increasing serotonergic levels, thereby, prolonging SS2. CASE PRESENTATION: A 28 year old male visiting from Europe with an unknown medical history was brought in to the hospital after sudden onset of diaphoresis, agitation, and confusion at a restaurant. He presented in status epilepticus with combative behavior leading to intubation, sedation, and paralysis. Seizure control required multiple agents. Initial objective data revealed no electrolyte or metabolic abnormalities, and negative toxicology. Imaging of the brain and infectious workup was unremarkable. Within hours, the patient became hyperthermic and hypertensive; pertinent exam findings included clonus and hyperreflexia. Based on these findings, SS versus sympathomimetic toxicity were the highest on our differential diagnosis. Treatment with cyproheptadine was initiated. The hospital course was prolonged and complicated by aspiration pneumonia, multiple deep vein thrombosis, and prolonged delirium. Higher amounts of Fentanyl and Propofol were required to maintain adequate sedation. The patient remained hypertensive, febrile, with signs of hyperreflexia, and clonus for seven days. Fentanyl was discontinued due to potential serotonergic additive effects. Rapid clinical signs of improvement were observed. It was ultimately discovered that the patient was using lysergic acid diethylamide (LSD). DISCUSSION: LSD is a widely used hallucinogen and a recognized cause of SS³. In the ICU, patients can be exposed to multiple serotonergic agents including opiates and antiemetics, thus, it is imperative clinicians are aware of which agents precipitate and prolong the course of SS. Moreover, each individual’s risk for developing and recovering from SS is dependent on several factors including age, liver, renal function, and genetic polymorphisms in the cytochrome P450 pathway. A thorough review of medications in the ICU may prevent further complications and result in a faster and favorable prognosis. CONCLUSIONS: Our case demonstrates a unique presentation of SS with a favorable outcome due to early suspicion of the diagnosis, recognition of serotonergic agents, and aggressive intervention. Reference #1: Wacker, D. (2017). Crystal Structure of an LSD-Bound Human Serotonin Receptor. Cell, 168(3), pp.377-389.e12. Reference #2: Greenier, E. (2014). Serotonin syndrome: fentanyl and selective serotonin reuptake inhibitor interactions. American Association of Nurse Anesthetists, 82(5), pp.340-5. Reference #3: Halberstadt, A. (2017). Hallucinogenic Drugs: A New Study Answers Old Questions about LSD. Current Biology, 27(4), pp.R156-R158. DISCLOSURES: No relevant relationships by Sujith Puskoor, source=Web Response No relevant relationships by Rebecca Saunders, source=Web Response No relevant relationships by Anita Singh, source=Web Response