Serotonin Syndrome Induced by Tramadol Intoxication in an 8-Month-Old Infant

Abstract

I read with interest the case presented by Maréchal et al. [ [1] Maréchal C. Honorat R. Claudet I. Serotonin syndrome induced by tramadol intoxication in an 8-month-old infant. Pediatr Neurol. 2011; 44: 72-74 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar ]. They reported, for the first time, on moderate serotonin syndrome in an 8-month-old girl after tramadol intoxication, and concluded that pediatricians should be aware of specific clinical manifestations of serotonin syndrome, to avoid any delay in management. Interestingly, the management used by the authors for their patients remains unclear. As is well known, patients who develop serotonin syndrome and present with agitation or neuromuscular hyperactivity (similar to the patient of Maréchal et al. [ [1] Maréchal C. Honorat R. Claudet I. Serotonin syndrome induced by tramadol intoxication in an 8-month-old infant. Pediatr Neurol. 2011; 44: 72-74 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar ]) should initially be managed with benzodiazepines [ [2] Lappin R.I. Auchincloss E.L. Treatment of the serotonin syndrome with cyproheptadine. N Engl J Med. 1994; 331: 1021-1022 Crossref PubMed Scopus (116) Google Scholar ]. Furthermore, the administration of cyproheptadine may improve the patient’s condition sooner. Cyproheptadine is a first-generation, histamine-1 receptor blocking agent with nonspecific antagonist properties at the 5HT-1A and 5HT-2A receptors. Patients with mild to moderate signs of serotonin syndrome, and who are not hyperthermic, typically respond to this pharmacologic agent within 30 minutes to 2 hours of administration [ 2 Lappin R.I. Auchincloss E.L. Treatment of the serotonin syndrome with cyproheptadine. N Engl J Med. 1994; 331: 1021-1022 Crossref PubMed Scopus (116) Google Scholar , 3 Graudins A. Stearman A. Chan B. Treatment of serotonin syndrome with cyproheptadine. J Emerg Med. 1998; 16: 615-619 Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar ]. Although this medication is not available in an intravenous form, tablets may be crushed and administered by nasogastric tube in pediatric patients. Moreover, despite the authors’ statement in their Discussion about the association of tramadol with selective serotonin reuptake inhibitors in the development of serotonin syndrome, an overdose of a single serotonin-potentiating agent such as tramadol may also produce serotonin syndrome [ [2] Lappin R.I. Auchincloss E.L. Treatment of the serotonin syndrome with cyproheptadine. N Engl J Med. 1994; 331: 1021-1022 Crossref PubMed Scopus (116) Google Scholar ]. Serotonin Syndrome Induced by Tramadol Intoxication in an 8-Month-Old InfantPediatric NeurologyVol. 44Issue 1PreviewSevere cases of pediatric tramadol intoxication are rarely reported. We report on serotonin syndrome after tramadol intoxication. An 8-month-old girl developed extreme agitation after accidentally ingesting a tablet of her father’s medication (Monocrixo LP (Thérabel Lucien Pharma, Levallois Perret, France), 200 mg tramadol). Unable to sleep, she was admitted the next morning to our Pediatric Emergency Department after an episode of epistaxis. Vital signs were significant for sinus tachycardia and a neurologic examination revealed intermediately reactive pupils, agitation alternating with drowsiness with a Glasgow Coma Scale of 10, and increased lower-limb reflexes. Full-Text PDF ResponsePediatric NeurologyVol. 46Issue 3PreviewI thank Dr. Sanaei-Zadeh for his accurate and expert comments about our case report. The management of this patient was not specified because it was mainly supportive. We did not need to use benzodiazepines because the girl manifested episodic agitation alternating with drowsiness. Her agitation was moderate at hospital, compared with her described neurologic status on the preceding night at home. Cyproheptadine was not prescribed because the staff pediatrician in the emergency unit did not recognize serotonin syndrome during the patient’s admission, and did not know that cyproheptadine was recommended for patients with severe toxicity, including children. Full-Text PDF