Case Report Of Serotonin Syndrome Research Articles

Síndrome serotoninérgica associada a uso de sertralina: relato de caso

Relato de caso de síndrome serotoninérgica em paciente que iniciou uso de sertralina em dose maior do que o dobro do recomendado para o tratamento de depressão psicótica. Apresentou contratura de membros, olhar perplexo, mutismo e pressão arterial (PA) de 230 x 110 mmHg. A síndrome é cada vez mais comum, mas não é bem reconhecida. Muitos medicamentos podem causá-la e deve-se considerar essa possibilidade em pacientes em uso de medicamentos serotoninérgicos que se apresentam com distúrbios autonômicos ou mentais e sintomas neurológicos. Os achados de clonus, crise oculógira, hiper-reflexia e hipertonicidade devem levar à revisão da medicação. O tratamento centra-se na cessação de agentes causadores, tratamento da possível hipertermia e uso de benzodiazepínicos para diminuir a hipertonia e a excitabilidade neurológica.

Famotidine-induced reversal of meperidine-related serotonin syndrome: a case report.

Serotonin syndrome is an unexpected fatal adverse event related to serotonergic medication. This case report is the first report describing the possible treatment effect of famotidine on serotonin syndrome. Furthermore, this is the first case report of serotonin syndrome induced by meperidine alone in a patient with no previous history suggesting a susceptibility to serotonin syndrome. A 70-year-old male with no recent history of serotonergic drug use presented with severe serotonin syndrome following ureteroscopy, possibly due to postoperative meperidine administration. The patient's symptoms included hypertension, tachycardia, tachypnea, hyperthermia, myoclonus, diaphoresis, retching, nausea, agitation, and semicoma mentality with no pupillary light reflex. Symptoms began to subside immediately after the administration of intravenous famotidine for prevention of aspiration pneumonia, with mental and neurological symptoms showing improvement initially, followed by autonomic symptoms. This case report suggests that the histamine type 2 receptor antagonist famotidine may be an effective emergency treatment for serotonin syndrome.

Serotonin syndrome overlapping with neuroleptic malignant syndrome: A case report and approaches for differentially diagnosing the two syndromes

Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are life-threatening adverse reactions caused by serotonergic antidepressants and neuroleptics, respectively. SS and NMS have overlapping clinical features, and thus differentially diagnosing the syndromes can be difficult in patients who are taking both types of drugs. Here, the author reports a unique case of a patient who developed SS that overlapped with NMS after taking imipramine and lithium carbonate with the subsequent addition of metoclopramide. This is the first case report of SS that overlapped with NMS. The author also briefly summarizes the clinical symptoms of each syndrome and describes the approaches that were used to differentially diagnose the two syndromes.

Serotonin syndrome: Risk with concurrent use of SSRIs and other serotonergic meds

Major depressive disorder affects 14.8 million Americans, with another 3.3 million having mild depression.1.www.adaa.org/about-adaa/press-room/factsstatisticsGoogle Scholar Both conditions are commonly treated with selective serotonin reuptake inhibitors (SSRIs) and other medications that affect serotonin, such as serotonin norepinephrine reuptake inhibitors (SNRIs). Other commonly prescribed medications that affect serotonin include the triptans and tramadol. A rare adverse effect of taking one or multiple serotonin-modulating agents is serotonin syndrome, which ranges from mild to life-threatening symptoms of agitation, restlessness, muscle rigidity, and autonomic hyperactivity.2.The Oschner J. 2013; 13: 533-540Google ScholarIn case reports, natural products including ginseng, tryptophan, and St. John's wort, as well as the OTC product dextromethorphan, have been associated with the development of serotonin syndrome in patients taking SSRIs. The mechanisms by which the products cause the syndrome may include inhibition of serotonin reuptake and metabolism, as well as increased serotonin synthesis and release.2.The Oschner J. 2013; 13: 533-540Google Scholar Although limited to case reports, this association is important because many Americans taking SSRIs regularly use OTCs and natural products, yet few read the entire label and seek a pharmacist's guidance.GinsengGinseng is used for conditions ranging from hypertension to fatigue. Its active components are ginsenosides, 12 of which have been isolated, each possessing varying activity on the CYP isoenzymes. The ginsenoside Rd showed inhibitory effects in vitro on CYP2C9, 2C19, 3A4, and 2D6 isoenzymes, which are important for SSRI metabolism.3.Drug Metab Rev. 2003; 35: 35-98Crossref PubMed Scopus (361) Google ScholarTryptophanSt. John's wortSt. John's wort has demonstrated modest efficacy in managing symptoms of mild depression, although this condition should never be self-treated. Case reports of serotonin syndrome with St. John's wort have been reported when used with sertraline or paroxetine.4.AAPS J. 2009; 11: 710-727Crossref PubMed Scopus (207) Google ScholarS-Adenosyl-L-Methionine (SAMe)SAMe is another natural product for depression. Due to its serotonergic properties, SAMe might also increase the risk of serotonin syndrome.DextromethorphanDextromethorphan (DXM) is a moderate serotonin reuptake inhibitor that simultaneously promotes serotonin release.5.Br J Clin Pharmacol. 2010; 70: 794-798Crossref PubMed Scopus (33) Google Scholar In one case, a 46-year-old man had been taking sertraline 100 mg daily for 2 years; his physician recommended an OTC product containing 30 mg of DXM per 30-mL dose. The patient drank 240 mL in one night, doubling the maximum dose, and was diagnosed the next day with serotonin syndrome.6.Prim Care Companion CNS Disord. 2012; 14: 121-122Geriatr Gerontol Int. 2011; 11Google Scholar This combination is potentially dangerous because sertraline may inhibit CYP2D6 metabolism of DXM. Another report described an episode of serotonin syndrome with DXM without prior use of SSRIs.7An older Japanese man with chronic hepatitis C and kidney disease was hospitalized with restlessness, unsteady voice, and involuntary movement following the use of DXM tablets 45 mg daily. This patient's impaired renal and hepatic function, as well as his age, may have increased his risk of serotonin syndrome.7Serotonin syndrome is a rare adverse effect of SSRIs and other serotonergic medications. Review with patients taking any of these medications their concurrent OTC and natural product usage to ensure a safe medication regimen. Major depressive disorder affects 14.8 million Americans, with another 3.3 million having mild depression.1.www.adaa.org/about-adaa/press-room/factsstatisticsGoogle Scholar Both conditions are commonly treated with selective serotonin reuptake inhibitors (SSRIs) and other medications that affect serotonin, such as serotonin norepinephrine reuptake inhibitors (SNRIs). Other commonly prescribed medications that affect serotonin include the triptans and tramadol. A rare adverse effect of taking one or multiple serotonin-modulating agents is serotonin syndrome, which ranges from mild to life-threatening symptoms of agitation, restlessness, muscle rigidity, and autonomic hyperactivity.2.The Oschner J. 2013; 13: 533-540Google Scholar In case reports, natural products including ginseng, tryptophan, and St. John's wort, as well as the OTC product dextromethorphan, have been associated with the development of serotonin syndrome in patients taking SSRIs. The mechanisms by which the products cause the syndrome may include inhibition of serotonin reuptake and metabolism, as well as increased serotonin synthesis and release.2.The Oschner J. 2013; 13: 533-540Google Scholar Although limited to case reports, this association is important because many Americans taking SSRIs regularly use OTCs and natural products, yet few read the entire label and seek a pharmacist's guidance. GinsengGinseng is used for conditions ranging from hypertension to fatigue. Its active components are ginsenosides, 12 of which have been isolated, each possessing varying activity on the CYP isoenzymes. The ginsenoside Rd showed inhibitory effects in vitro on CYP2C9, 2C19, 3A4, and 2D6 isoenzymes, which are important for SSRI metabolism.3.Drug Metab Rev. 2003; 35: 35-98Crossref PubMed Scopus (361) Google Scholar Ginseng is used for conditions ranging from hypertension to fatigue. Its active components are ginsenosides, 12 of which have been isolated, each possessing varying activity on the CYP isoenzymes. The ginsenoside Rd showed inhibitory effects in vitro on CYP2C9, 2C19, 3A4, and 2D6 isoenzymes, which are important for SSRI metabolism.3.Drug Metab Rev. 2003; 35: 35-98Crossref PubMed Scopus (361) Google Scholar Tryptophan St. John's wortSt. John's wort has demonstrated modest efficacy in managing symptoms of mild depression, although this condition should never be self-treated. Case reports of serotonin syndrome with St. John's wort have been reported when used with sertraline or paroxetine.4.AAPS J. 2009; 11: 710-727Crossref PubMed Scopus (207) Google Scholar St. John's wort has demonstrated modest efficacy in managing symptoms of mild depression, although this condition should never be self-treated. Case reports of serotonin syndrome with St. John's wort have been reported when used with sertraline or paroxetine.4.AAPS J. 2009; 11: 710-727Crossref PubMed Scopus (207) Google Scholar S-Adenosyl-L-Methionine (SAMe)SAMe is another natural product for depression. Due to its serotonergic properties, SAMe might also increase the risk of serotonin syndrome. SAMe is another natural product for depression. Due to its serotonergic properties, SAMe might also increase the risk of serotonin syndrome. DextromethorphanDextromethorphan (DXM) is a moderate serotonin reuptake inhibitor that simultaneously promotes serotonin release.5.Br J Clin Pharmacol. 2010; 70: 794-798Crossref PubMed Scopus (33) Google Scholar In one case, a 46-year-old man had been taking sertraline 100 mg daily for 2 years; his physician recommended an OTC product containing 30 mg of DXM per 30-mL dose. The patient drank 240 mL in one night, doubling the maximum dose, and was diagnosed the next day with serotonin syndrome.6.Prim Care Companion CNS Disord. 2012; 14: 121-122Geriatr Gerontol Int. 2011; 11Google Scholar This combination is potentially dangerous because sertraline may inhibit CYP2D6 metabolism of DXM. Another report described an episode of serotonin syndrome with DXM without prior use of SSRIs.7An older Japanese man with chronic hepatitis C and kidney disease was hospitalized with restlessness, unsteady voice, and involuntary movement following the use of DXM tablets 45 mg daily. This patient's impaired renal and hepatic function, as well as his age, may have increased his risk of serotonin syndrome.7Serotonin syndrome is a rare adverse effect of SSRIs and other serotonergic medications. Review with patients taking any of these medications their concurrent OTC and natural product usage to ensure a safe medication regimen. Dextromethorphan (DXM) is a moderate serotonin reuptake inhibitor that simultaneously promotes serotonin release.5.Br J Clin Pharmacol. 2010; 70: 794-798Crossref PubMed Scopus (33) Google Scholar In one case, a 46-year-old man had been taking sertraline 100 mg daily for 2 years; his physician recommended an OTC product containing 30 mg of DXM per 30-mL dose. The patient drank 240 mL in one night, doubling the maximum dose, and was diagnosed the next day with serotonin syndrome.6.Prim Care Companion CNS Disord. 2012; 14: 121-122Geriatr Gerontol Int. 2011; 11Google Scholar This combination is potentially dangerous because sertraline may inhibit CYP2D6 metabolism of DXM. Another report described an episode of serotonin syndrome with DXM without prior use of SSRIs.7 An older Japanese man with chronic hepatitis C and kidney disease was hospitalized with restlessness, unsteady voice, and involuntary movement following the use of DXM tablets 45 mg daily. This patient's impaired renal and hepatic function, as well as his age, may have increased his risk of serotonin syndrome.7 Serotonin syndrome is a rare adverse effect of SSRIs and other serotonergic medications. Review with patients taking any of these medications their concurrent OTC and natural product usage to ensure a safe medication regimen.

Occurrence of Milnacipran-Associated Morbilliform Rash and Serotonin Toxicity

To report the development of morbilliform rash and serotonin toxicity after the addition of milnacipran to a patient's medication therapy. A 57-year-old white female presented to the emergency department because of a full-body morbilliform rash, which appeared 9 days after initiation of milnacipran 50 mg twice daily. In the emergency department the patient's vital signs were: heart rate 121 beats/min, blood pressure 180/100 mm Hg, and temperature 38.9 °C. The patient reported diarrhea, nausea, dizziness, restlessness, and increased muscle pain. Her history included recurrent breast cancer first diagnosed in 1999, hypertension, fibromyalgia, depression, osteopenia, gastroesophageal reflux disease, insomnia, and endometriosis. Her home medications included milnacipran, fluoxetine, alprazolam, zolpidem, zoledronic acid, anastrozole, doxepin, ranitidine, levocetirizine, doxazosin, tramadol, vitamin D, and ferrous gluconate. The patient's increased heart rate, blood pressure, and temperature, as well as restlessness, self-reported diarrhea and nausea, and self-reported increase in muscle pain, indicated serotonin toxicity. Milnacipran, fluoxetine, and tramadol were discontinued, while doxepin was continued. Treatment consisted of acetaminophen, diphenhydramine, methylprednisolone, promethazine, and hydralazine 10 mg intravenously. The following morning all vital signs were within normal limits and the patient's diarrhea, nausea, dizziness, restlessness, and muscle pain resolved. She was discharged the following morning. The rash had resolved after day 2 of hospital discharge, which was the fourth day after discontinuation of milnacipran. Given the patient's symptoms, the timing of symptom onset, the patient's history, and findings on physical examination, as well as use of the Naranjo probability scale, milnacipran was deemed the probable cause of the morbilliform reaction and serotonin toxicity. Only 1 case report of rash and 2 case reports of serotonin syndrome associated with milnacipran have been reported. It is important to increase awareness of the possibility of developing morbilliform rash and serotonin toxicity with milnacipran therapy, as both conditions can be associated with poor outcomes if not detected early and treated appropriately.

The FDA Alert on Serotonin Syndrome With Use of Triptans Combined With Selective Serotonin Reuptake Inhibitors or Selective Serotonin‐Norepinephrine Reuptake Inhibitors: American Headache Society Position Paper

In 2006, a US Food and Drug Administration (FDA) alert warned about the potential life-threatening risk of serotonin syndrome when triptans are used in combination with selective serotonin reuptake inhibitors (SSRIs) or selective serotonin/norepinephrine reuptake inhibitors (SNRIs). This American Headache Society Position Paper further reviews the available evidence of the potential risk of combining triptans with other serotonergic agents. Using the Sternbach Criteria or the Hunter Serotonin Toxicity Criteria, the 29 cases used as the basis for the FDA alert were assessed in addition to a more recently published clinical review of 11 case reports of serotonin syndrome resulting from monotherapy, and one report of combination serotonergic agents. Evidence was evaluated according to the American Academy of Neurology Clinical Practice Guideline Process Manual. Collectively, 40 case reports are available in the literature for subjects receiving either combination or monotherapy of serotonin agonists, all of which are limited to Class IV level of evidence. Of the 29 cases used as the basis for the FDA alert, 10 cases actually met the Sternbach Criteria for diagnosing serotonin syndrome. No cases fulfilled the Hunter Criteria for serotonin toxicity. One case published since the original report does not meet either criteria, and subsequently reported cases involving triptan monotherapy include insufficient details to confirm a diagnosis of serotonin syndrome. With only Class IV evidence available in the literature and available through the FDA registration of adverse events, inadequate data are available to determine the risk of serotonin syndrome with the addition of a triptan to SSRIs/SNRIs or with triptan monotherapy. The currently available evidence does not support limiting the use of triptans with SSRIs or SNRIs, or the use of triptan monotherapy, due to concerns for serotonin syndrome (Level U). However, given the seriousness of serotonin syndrome, caution is certainly warranted and clinicians should be vigilant to serotonin toxicity symptoms and signs to insure prompt treatment. Health care providers should report potential cases to MedWatch and consider submitting them for publication.

P291 Case report of serotonin syndrome in a 14 year old girl

P291 Case report of serotonin syndrome in a 14 year old girl

Serotonin Syndrome in Elderly Patients Treated for Psychotic Depression with Atypical Antipsychotics and Antidepressants: Two Case Reports

We report two cases of serotonin syndrome in elderly patients during treatment of psychotic depression with atypical antipsychotics and antidepressants. The first case is a 69-year-old man who was admitted for depression with psychosis and treated with trazodone, risperidone, and sertraline. Subsequently, he developed myoclonus, tremor, cogwheel rigidity, and diaphoresis. The second case is a 72-year-old female initially admitted to a medical inpatient unit for a change in mental status that presented as increased confusion, lethargy, slurred speech, and a fever of 101.5 degrees. She had been on phenelzine and quetiapine. In both cases, all symptoms resolved within 24 hours of the psychotropics being stopped. In both cases, we believe that serotonin syndrome was produced by a combination of an antidepressant and an atypical antipsychotic. There have been several case reports of serotonin syndrome from similar combinations of antidepressant and atypical antipsychotic treatment. Clinicians treating elderly patients with a combination of serotonergic antidepressants and atypical antipsychotics for psychotic depression should be aware of the potential for serotonin syndrome.

Risk of Serotonin Syndrome with Concomitant Administration of Linezolid and Serotonin Agonists

Linezolid, an antimicrobial used to treat resistant gram-positive bacteria, can inhibit monoamine oxidase, an enzyme that metabolizes serotonin and other biogenic amines. Inhibition of this enzyme can predispose patients who are concomitantly taking serotonin agonists to serotonin syndrome. Because of the potential of linezolid to inhibit monoamine oxidase, premarketing studies were conducted with drugs such as selective serotonin reuptake inhibitors. No cases of serotonin syndrome were recorded. After linezolid was released to the United States market, several case reports of serotonin syndrome emerged. A literature search revealed 13 cases of serotonin syndrome occurring with the concomitant use of linezolid and drugs possessing serotonergic properties. To direct clinical management of this potential drug interaction, we reviewed reports of serotonin syndrome to determine relevant drug interactions with linezolid and serotonergic drugs and to characterize similarities and differences in the reported cases. Clinicians should obtain complete drug histories to identify patients at risk, strictly monitor drug therapy including concomitant drugs, and receive education about this potential drug interaction and the symptoms of serotonin syndrome.

Linezolid and Serotonergic Drug Interactions: A Retrospective Survey

Linezolid is a reversible, nonselective monoamine oxidase inhibitor. There are currently 11 published case reports of serotonin syndrome being associated with linezolid and selective serotonin reuptake inhibitors (SSRIs). Controversy exists regarding whether linezolid and SSRIs can be given concomitantly. The purpose of this study was to report the incidence of serotonin syndrome in patients receiving linezolid and SSRIs. This study was a retrospective chart review of inpatients at the Mayo Clinic (Rochester, MN) with concomitant orders or therapy within 14 days for linezolid and an SSRI from 2000 to 2004. The Sternbach criteria and Boyer criteria for diagnosis of serotonin syndrome were used to identify clinical features of serotonin syndrome. Seventy-two patients received linezolid and an SSRI or venlafaxine within 14 days of each other. Fifty-two patients (72%) received concomitant therapy with linezolid and an SSRI or venlafaxine, and 20 patients (28%) did not receive concomitant therapy but received linezolid and an SSRI within a 14-day period. Overall, only 2 patients (3%) had a high probability of serotonin syndrome. In both patients with high probability, symptoms reversed rapidly on discontinuation of serotonergic therapy. The Boyer criteria were much more specific than the Sternbach criteria for identification of serotonin syndrome. On the basis of our experience, we suggest that, if the clinical situation warrants use of linezolid in a patient receiving an SSRI, linezolid may be used concomitantly with SSRIs, without a 14-day washout period and with careful monitoring for signs and symptoms of serotonin syndrome. Serotonergic agents should be promptly discontinued if serotonin syndrome is suspected.

A Case Report of Serotonin Syndrome Associated With Combined Nefazodone and Fluoxetine

Article AbstractLetter to the Editor Sir: Serotonin syndrome is a potentially lethal conditioncaused by excessive serotonergic activity and is diagnosed bythe presence of at least 3 of 10 symptoms: mental status changes(confusion, hypomania), agitation, myoclonus, hyperreflexia,diaphoresis, shivering, tremor, diarrhea, incoordination, and fever. It most frequently develops after coadministration of 2serotomimetic agents, 1 of which is often (but not always) amonoamine oxidase inhibitor. To our knowledge, the followingis the first report of serotonin syndrome involving the combinationof nefazodone, a 5-HT2 antagonist, and fluoxetine, a selectiveserotonin reuptake inhibitor (SSRI).

Myoclonus Associated with Parenteral Meperidine in a Two-Year-Old Boy

A case of suspected myoclonus in a 2-year-old male after multiple doses of meperidine given intramuscularly is reported. Meperidine, as well as many other drugs possess serotonin reuptake inhibitor activity and in this report the interaction between several drugs with similar activity may have contributed to the adverse effects seen. It is theorized that since the clinical presentation of myoclonus is included in case reports of serotonin syndrome in the literature this adverse reaction may in fact be part of this syndrome. It is proposed that the name serotonin syndrome may mislead investigators and it may be better thought of as a progression of increasingly serious sequelae that may occur more frequently than clinicians realize. It is important for physicians and caregivers to educate themselves on the cumulative effects that serotonin like drugs like normeperidine may exhibit, especially in combination. In an acute setting when renal and hepatic function may be compromised or in the elderly or young w...