Cardiogenic shock and status epilepticus after massive bupropion overdose

Delayed Serotonin Syndrome and Non-cardiogenic Pulmonary Edema Following Bupropion Overdose in a Seven-Year-Old Female: A Case Report and Review of Literature

Bupropion is an atypical antidepressant prescribed for depression and attention-deficit/hyperactivity disorder and to aid in smoking cessation. Bupropion overdose management is largely aimed toward common sequelae, including seizures, tachycardia, and QTc prolongation. In this case report, we identify a rare event of pediatric bupropion overdose with aforementioned common sequela and atypical features, including a delayed presentation of serotonin syndrome and non-cardiogenic pulmonary edema. This case follows a seven-year-old Caucasian female with autism spectrum disorder (ASD) who presented in status epilepticus following an accidental bupropion overdose and required multiple anti-seizure medications, endotracheal intubation, and admission to the pediatric intensive care unit (PICU). The patient's condition improved, and she was extubated 25 hours after admission and transitioned to high-flow nasal cannula therapy. On day 3 of admission, she became febrile and developed dyspnea with decreased breath sounds and intercostal retractions, tachycardia, a rigid abdomen and extremities with sporadic tremors, pulmonary edema, and a prolonged QTc interval. Targeted therapies were initiated, and following treatment, our patient showed remarkable improvement in the subsequent 24 hours and was discharged home five days after the initial presentation. This case identifies a delayed presentation of uncommon and serious complications of bupropion overdose, including pulmonary edema and serotonin syndrome, in a pediatric patient. Prompt investigation and identification of bupropion toxicity can help practitioners mitigate further complications during admission and reduce morbidity and mortality.

Successful Treatment of Confirmed Severe Bupropion Cardiotoxicity With Veno-Arterial Extracorporeal Membrane Oxygenation Initiation Prior to Cardiac Arrest

Bupropion is a substituted cathinone (β-keto amphetamine) norepinephrine/dopamine reuptake inhibitor andnoncompetitive nicotinic acetylcholine receptor antagonist that is frequently used to treat major depressive disorder. Bupropion overdose can cause neurotoxicity and cardiotoxicity, the latter of which is thought to be secondary to gap junction inhibition and ion channel blockade. We report a patient with a confirmed bupropion ingestion causing severe cardiotoxicity, for whom prophylactic veno-arterial extracorporeal membrane oxygenation (ECMO) was successfully implemented. The patient was placed on the ECMO circuit several hours before he experienced multiple episodes of hemodynamically unstable ventricular tachycardia, which were treated with multiple rounds of electrical defibrillation and terminated after administration of lidocaine. Despite a neurological examination notable for fixed and dilated pupils after ECMO cannulation, the patient completely recovered without neurological deficits. Multiple bupropion and hydroxybupropion concentrations were obtained and appear to correlate with electrocardiogram interval widening and toxicity.

Use of Multimodal Mechanical Support in Refractory Cardiogenic Shock From Bupropion Overdose

Massive bupropion overdose has a known association with cardiogenic shock. We describe a clinical case of a 48-year-old female who was brought to the hospital by emergency medical services after ingesting numerous psychiatric medications. Her hospital course was complicated by worsening cardiogenic shock and ventricular tachycardia storm. Transthoracic echocardiography showed left ventricular (LV) hypokinesis with an ejection fraction of 9%. Then the patient underwent placement of a percutaneous Impella CP device (Abiomed, Danvers, MA). The Molecular Adsorbent Recirculating System was started for protein-bound bupropion clearance. After 24 hours, the patient returned to an organized sinus rhythm. A repeat echocardiogram done on the next day demonstrated improved LV function, and the patient had profound clinical improvement. The case illustrates how the use of extracorporeal membrane oxygenation in combination with Impella device and Molecular Adsorbent Recirculating System was able to support the patient's recovery.

Acute intoxication following massive bupropion sniffing: A case report

Bupropion intranasal misuse potential should be considered in the suspect of sympathomimetic syndrome for illicit drug or medication intoxication. A 31-year-old man was admitted for intranasal misuse of 30 crushed tablets of bupropion with adrenergic mild presentation. Lorazepam infusion was started with complete clinical resolution. Further forensic investigations detected a bupropion serum and urine concentration levels at 18 hours from intake of 1905.26 ng/mL and 2001.57 ng/mL, respectively. This case of intranasal bupropion misuse shared only some features with oral overdose, despite a plasma concentration five times higher than the lowest toxic level. Nasal bupropion snorting in chronic users could have lower toxicity compared to other snorted stimulants but symptomatic treatment remains the gold standard for preventing complications. Bupropion misuse might rapidly become a concerning issue and monitoring by healthcare professionals is needed.

A 19-Year-Old Woman with a History of Depression and Fatal Cardiorespiratory Failure Following an Overdose of Prescribed Bupropion

BACKGROUND Bupropion is a norepinephrine/dopamine-reuptake inhibitor (NDRI) that has been reported to increase the risk of suicide attempts in some patients. This report is of a case of a 19-year-old woman with a history of depression who suffered fatal cardiorespiratory failure following an overdose of prescribed bupropion. CASE REPORT A 19-year-old woman presented to the Emergency Department with an estimated bupropion overdose of 28.2 g and possible oxcarbazepine co-ingestion. This serum level was estimated based on the patient's history of medication reconciliation and number of pills remaining in the prescription bottle at presentation. The patient was unresponsive on arrival to the Emergency Department and was treated for intermittent seizures and shock. Despite aggressive medical interventions, her condition progressed to cardiogenic shock and eventually cardiac arrest, from which she could not be resuscitated. Several existing reports regarding bupropion overdose describe sinus tachycardia and seizures corrected by symptomatic treatment. This case may document the highest reported ingestion of bupropion recorded thus far in the literature and demonstrates the rapid onset of cardiac dysfunction and cardiogenic shock. CONCLUSIONS In the context of this case, we discuss the clinical manifestations of bupropion overdose and the rapid progression to cardiogenic shock. By examining the pathophysiology of overdose in an adolescent who consumed an extremely high dose of bupropion, we hope this information can be helpful to clinicians who are managing similarly challenging critical cases.

Atypical Findings in Massive Bupropion Overdose: A Case Report and Discussion of Psychopharmacologic Issues

Bupropion is an atypical antidepressant that is structurally similar to amphetamines. Its primary toxic effects include seizure, sinus tachycardia, hypertension, and agitation; however, at higher amounts of ingestion, paradoxical cardiac effects are seen. We report the case of a 21-year-old woman who ingested 13.5 g of bupropion, a dose higher than any other previously reported. The patient presented with seizure, sinus tachycardia with prolonged QTc and QRS intervals, dilated pupils, and agitation. Four days after overdose, the patient's sinus tachycardia and prolonged QTc and QRS intervals resolved with symptomatic management, but she soon developed sinus bradycardia, hypotension, and mild transaminitis. With continued conservative management and close monitoring, her sinus bradycardia resolved 8 days after the overdose. The transaminitis resolved 12 days after the overdose. Our findings are consistent with previously reported toxic effects associated with common overdose amounts of bupropion. In addition, we have observed transient cardiotoxicity manifesting as sinus bradycardia associated with massive bupropion overdose. These findings are less frequently reported and must be considered when managing patients with massive bupropion overdose. We review the psychopharmacologic implications of this and comment on previous literature.

Bupropion Overdose Presenting as Status Epilepticus in an Infant

BACKGROUND

Bupropion is a monocyclic antidepressant in the aminoketone class, structurally related to amphetamines. The Food and Drug Administration withdrew this product from the market in 1986 after seizures were reported in bulimic patients. It was later reintroduced in 1989 when the incidence of seizures was shown to be dose-related in the immediate release preparation. Massive bupropion ingestion has been associated with status epilepticus and cardiogenic shock in adults. Seizures have been reported in children, but not status epilepticus. This report highlights a patient who presented with status epilepticus and developed cardiopulmonary arrest after bupropion ingestion. False-positive amphetamine diagnosis from urine drug screen on presentation was reported.

METHOD

We review the presentation, clinical course, diagnostic studies, and outcome of this patient. We then review the literature regarding bupropion overdose in children.

RESULT

Symptoms of bupropion toxicity and risk for seizures are dose-dependent and fatalities have been reported. Our patient developed status epilepticus and cardiopulmonary arrest and then progressed to have a hypoxic ischemic encephalopathy and refractory symptomatic partial seizures.

CONCLUSION

Our report highlights the need to keep this medication away from children in order to prevent accidental overdose.

Tobacco smoking, epilepsy, and seizures

Tobacco smoking is considered the greatest risk factor for death caused by noncommunicable diseases. In contrast to extensive research on the association between tobacco smoking and diseases such as heart attack, stroke, and cancers, studies on the association between tobacco smoking and seizures or epilepsy are insufficient. The exact roles tobacco smoking and nicotine use play in seizures or epilepsy have not been well reviewed. We reviewed available literature and found that 1) there are vast differences between tobacco smoke and nicotine based on their components and their effects on seizures or epilepsy; 2) the seizure risk in acute active tobacco smokers, women who smoke during pregnancy, electronic cigarette smokers, and the role of smoking in sudden unexplained/unexpected death in epilepsy remain unclear; 3) seizure risks are higher in acute secondhand smokers, chronic active smokers, and babies whose mothers smoke; 4) tobacco smoke protects against seizures in animal models whereas nicotine exerts mixed effects in animals; and 5) tobacco smoking agents can be noneffective, proconvulsant, or anticonvulsant. Finally, the opportunities for future research on this topic is discussed.

Dilated and unreactive pupils and burst-suppression on electroencephalography due to buproprion overdose

Burst-suppression pattern on electroencephalography (EEG) occurs upon dissociation of the cortex from underlying brain structures. Unless the pattern is a physiologic consequence of administered sedatives, this electroencephalographic pattern is indicative of a poor neurologic outcome and high mortality. We report a case of a 29-year-old female thought to be brain dead based on initial physical examination and EEG findings of burst-suppression, who was later found to have supratherapeutic serum levels of bupropion. This is the second documented case of burst-suppression pattern on EEG in a patient who overdosed on bupropion. We propose that burst-suppression in the setting of bupropion toxicity may revert with drug clearance.

Assessment of the convulsant liability of antidepressants using zebrafish and mouse seizure models

In the past, antidepressants have been thought to possess proconvulsant properties. This assumption remains controversial, however, because anticonvulsant effects have been attributed to certain antidepressants. To date, it remains unclear which antidepressants can be used for the treatment of patients with epilepsy with depression. The present study was designed to determine the anticonvulsant and/or proconvulsant effects of three antidepressants (citalopram, reboxetine, bupropion) against pilocarpine- and pentylenetetrazole-induced acute seizures in larval zebrafish and mice. In zebrafish, all antidepressants were anticonvulsant in the pentylenetetrazole model. In addition, citalopram was anticonvulsant in the zebrafish pilocarpine model, whereas reboxetine and bupropion were without significant effect. In mice all three antidepressants increased some thresholds for pentylenetetrazole-induced convulsive-like behaviors at varying doses, whereas thresholds for pilocarpine-induced convulsive-like behaviors were generally lowered, particularly at the highest doses tested. In general we conclude that the convulsant liability of antidepressants is model and concentration dependent.

QRS widening and QT prolongation under bupropion: a unique cardiac electrophysiological profile

QRS widening and QT prolongation are associated with bupropion. The objectives were to elucidate its cardiac electrophysiological properties. Patch-clamp technique was used to assess the I(Kr) -, I(Ks) -, and I(Na) -blocking effects of bupropion. Langendorff retroperfusion technique on isolated guinea-pig hearts was used to evaluate the MAPD(90) -, MAP amplitude-, phase 0 dV/dt-, and ECG-modulating effects of bupropion and of two gap junction intercellular communication inhibitors: glycyrrhetinic acid and heptanol. To evaluate their effects on cardiac intercellular communication, fluorescence recovery after photobleaching (FRAP) technique was used. Bupropion is an I(Kr) blocker. IC(50) was estimated at 34 μm. In contrast, bupropion had hardly any effect on I(Ks) and I(Na) . Bupropion had no significant MAPD(90) -modulating effect. However, as glycyrrhetinic acid and heptanol, bupropion caused important reductions in MAP amplitude and phase 0 dV/dt. A modest but significant QRS-widening effect of bupropion was also observed. FRAP experiments confirmed that bupropion inhibits gap junctional intercellular communication. QT prolongation during bupropion overdosage is due to its I(Kr) -blocking effect. QRS widening with bupropion is not related to cardiac sodium channel block. Bupropion rather mimics the QRS-widening, MAP amplitude- and phase 0 dV/dt -reducing effect of glycyrrhetinic acid and heptanol. Unlike class I anti-arrhythmics, bupropion causes cardiac conduction disturbances by reducing cardiac intercellular coupling.

The uncommon causes of status epilepticus: a systematic review

This paper reports the first systematic review of uncommon causes of status epilepticus reported in the literature between 1990 and 2008. Uncommon causes are defined as those not listed in the main epidemiological studies of status epilepticus. 181 causes were identified. These were easily categorised into 5 specific aetiological categories: immunological disorders, mitochondrial disorders, infectious diseases, genetic disorders and drugs/toxins. A sixth category of 'other causes' has also been included. Knowledge of these causes is important for clinical management and treatment, and also for a better understanding of the pathophysiology of status epilepticus.

Medically serious adverse effects of newer antidepressants

Although safer than tricyclic antidepressants and monoamine oxidase inhibitors, the newer antidepressants may be associated with certain medically serious adverse effects, of which cardiovascular adverse effects, seizures, abnormal bleeding, hyponatremia, and agranulocytosis are discussed in this review. Data regarding the incidence and risk factors are summarized, and strategies for reducing the risk of these adverse effects and managing them are suggested. Identification of risk factors, appropriate antidepressant choice, and, when possible, careful monitoring may substantially reduce the incidence of these adverse effects and the morbidity associated with them.