Page 24 - Delaware Medical Journal - November 2015
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CASE REPORT
anti-psychotic. Research has shown that Fluoxetine extends the half-life and plasma concentration of Perphenazine, thus, increasing the risk of severe serotonin syndrome.1
The diagnosis of serotonin syndrome
patients with minor symptoms. Certain symptoms, like GI disturbance, anxiety, agitation, and dis-coordination can be seen with both overdose and withdrawals of SSRIs.7 Furthermore, symptoms like agitation and confusion may be a part
of the patient’s baseline psychiatric problem.7 Sternbach criteria, while providing some guideline towards Instead clinical suspicion should drive
the management.7 In most cases, there
studies to aid the diagnosis. A urine drug screen can be helpful in the detection
of co-ingested medications that may potentiate serotonin syndrome. Creatine phosphokinase (CPK) or myoglobin levels can help in determining extent
of muscle breakdown. Measurement of
establishing the diagnosis.6
Management of serotonin syndrome is mostly supportive. Cessation of any possible offending agents including
REFERENCES
1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112-1120.
2. Frank C. Recognition and treatment of serotonin syndrome: case report. Can Fam Physician. 2008;54:988-992.
3. Gupta V, Karnik N, Deshpande R, Patil M. Linezolid-induced serotonin syndrome. BMJ Case Rep. 2013. Available at: http://casereports.bmj.com/content/2013/bcr-2012-008199.abstract.
SSRI, MOI inhibitors, antipsychotics,
or antibiotics is necessary. Usually symptoms will resolve within 24-48 hours as the levels of 5-HT decrease.1,6 Once removed, the severity of symptoms should drive the aggressiveness of treatment. Mild cases (no hyperthermia, maintained airway) can be controlled with benzodiazepines while severe cases may and administration of a 5-HT antagonist, like Cyproheptadine. If symptoms do not begin to resolve, other diagnosis should be considered and pursued.1,6 If a high level of suspicion and prompt actions are taken, most cases of SS can be prevented.
TAKE HOME POINTS
Serotonin syndrome is a clinical diagnosis and a high level of suspicion is necessary for proper diagnosis and management.
Sternbach criteria is helpful in clinical diagnosis but should not overrule a high level of clinical suspicion as presentation can be very atypical.
care, cessation of offending agents and treatment with benzodiazepines or 5-HT antagonists, depending on severity.
CONTRIBUTING AUTHORS
■ VISHAKA RAGUVEER, MD is a Resident in
the Family Medicine Residency Program at Saint Francis Hospital in Wilmington, Del.
■ AKASH VARSHNEY, MD is an Internal Medicine Specialist working with IPC, the Hospitalist Group in Delaware
■ JOHN D’AMBROSIO, DO is the Chairperson of the Critical Care Committee at Saint Francis Hospital in Wilmington, Del.
4. 5. 6. 7.
Haberzettl R, Bert B, Fink H, Fox M. Animal models of the serotonin syndrome: a systematic review. Behav Brain Res. 2013;256:328-345.
Watts S, Morrison S, Davis R, Barman S. Serotonin and blood pressure regulation. Pharmacol Rev. 2012;64:359-388.
Arora B, Kannikeswaran K. The serotonin syndrome – the need for physician’s awareness. Intl J Emerg Med. 2010;3:373-377.
Mackay FJ, Dunn NR, Dunn, RD. Antidepressants and the serotonin syndrome in general practice. Br J Gen Pract. 1999;49:871-874.
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