Serotonin syndrome

Serotonin Syndrome With Concomitant Antidepressant and Tramadol: A Case Report

Serotonin syndrome (SS) is a potentially life-threatening condition that results from the excess of serotonergic activity in the central nervous system. It is classically described as a triad of neuromuscular abnormalities, altered mental status, and autonomic hyperactivity; these are, most often, due to iatrogenic drug interactions or intentional overdose. This case study is about a 58-year-old woman who was being treated with venlafaxine and tramadol due to her past medical history of major depressive disorder and neuropathic pain. These symptoms appeared after a mastectomy, which was performed to treat an invasive ductal carcinoma. The sudden increase of the antidepressant medication and the interaction with another drug that inhibits serotonin reuptake (tramadol) led to tremor, hyperreflexia, diarrhea, tachycardia, hypertension, and fever, meeting Hunter's criteria for diagnosis of serotonergic syndrome. She received supportive care and diazepam, and the offending agents were removed. The signs and symptoms were reverted in less than 24 hours. An increased use of agents affecting the serotonergic system to treat different medical conditions raises the likelihood of a higher prevalence and clinical impact of SS in the future. For this reason, it is crucial to raise awareness of this condition to prevent adverse outcomes.

Acute Cocaine Intoxication Leading to Multisystem Dysfunction: A Case Report

Cocaine intoxication presents a significant public health concern globally, with its use widespread in various regions. This case report outlines the challenging management of a 30-year-old male who presented with acute cocaine intoxication, leading to multiple organ failure and eventual death. The patient exhibited classic symptoms of cocaine intoxication preceding a fall, resulting in severe injuries. Despite aggressive resuscitative measures, the patient deteriorated rapidly, developing rhabdomyolysis, disseminated intravascular coagulation, acute kidney injury, and acute myocardial infarction. Differential diagnoses were considered, ruling out other possible causes. The patient's condition continued to worsen despite treatment, ultimately culminating in cardiac arrest and demise. This case underscores the complexity of managing acute cocaine intoxication and assessing many differential diagnoses, highlighting the importance of early recognition and aggressive intervention to mitigate adverse outcomes. In patients with altered mental status and hemodynamic instability, particularly in areas where drug use is common, cocaine intoxication should be considered as a possible cause.

Drug-Drug Interactions of Selective Serotonin Reuptake Inhibitors: A Pharmacovigilance Study on Real-World Evidence from the EudraVigilance Database

As the most common psychiatric symptom, depression represents a subject of high interest for the medical community. Background/Objectives: International guidelines consider selective serotonin reuptake inhibitors (SSRIs) the first-line treatment of depression. Although having better efficacy and tolerability in comparison to tricyclic antidepressants or monoamine oxidase inhibitors, the diversity and potential severity of adverse effects and interactions manifested by SSRIs, combined with the frequency of prescriptions, lead to the necessity of evaluating real-world data. The aim of this study was to identify and evaluate the drug interactions reported in EudraVigilance (EV) for the six SSRIs representatives that are authorized in Europe: fluoxetine (FXT), fluvoxamine (FVM), citalopram (CIT), escitalopram (ESC), paroxetine (PAR) and sertraline (SER). The entire class of SSRIs was examined as a comparator to identify whether one of the representatives was more prone to reporting. Methods: Descriptive analysis and disproportionality analysis were conducted on data extracted from the EV database. Results: A total of 326,450 adverse reactions (ADRs) were reported for the SSRIs group. Approximately a quarter of these (n = 83,201; 25.46%) were reported for SER and 22.37% (n = 73,131) for PAR. Of the total ADRs reported, 2.12% (n = 6925) represent preferred terms related to drug-drug interactions (DDIs): SER (n = 1474; 22.37%), CIT (n = 1272, 19.86), and FXT (n = 1309, 19.83%). Specific ADRs related to inhibitory activity represent 0.98%, and for potentiating activity, 1.89%. Conclusions: Although representing a small value of the total ADRs, DDIs may be related to severe outcomes. Awareness should be raised for this category of ADRs that can be reduced by the joined efforts of physicians and pharmacists.

A False-positive Diagnosis of a Lethal Serotonin Syndrome Based on Postmortem Whole-blood Levels of Sertraline: How Forensic Detective Work Uses Medical Knowledge and Clinical Pharmacology to Solve Cases

This column is the third in a 3-part series describing cases in which general medical knowledge, including psychiatric and clinical pharmacology, was instrumental in determining whether dereliction was the direct cause of damages in a malpractice suit. This case illustrates how not taking into account the following variables can result in a false-positive diagnosis of a lethal serotonin syndrome: (a) the time course of treatment, (b) the time course of symptoms, (c) the difference between antemortem plasma and postmortem whole-blood levels of highly protein bound and highly lipophilic drugs. The case also illustrates how taking those 3 variables into account led to the conclusion that there was no dereliction in the care of the patient that was the direct cause of his death, and hence, there was no medical malpractice.

Neuroleptic malignant syndrome and serotonin syndrome: a comparative bibliometric analysis

OBJECTIVE

This study aimed to analyze and map scientific literature on Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) from prestigious, internationally indexed journals. The objective was to identify key topics, impactful articles, prominent journals, research output, growth patterns, hotspots, and leading countries in the field, providing valuable insights for scholars, medical students, and international funding agencies.

METHODS

A systematic search strategy was implemented in the PubMed MeSH database using specific keywords for NMS and SS. The search was conducted in the Scopus database, renowned for its extensive coverage of scholarly publications. Inclusion criteria comprised articles published from 1950 to December 31st, 2022, restricted to journal research and review articles written in English. Data were analyzed using Microsoft Excel for descriptive analysis, and VOSviewer was employed for bibliometric mapping.

RESULTS

The search yielded 1150 articles on NMS and 587 on SS, with the majority being case reports. Growth patterns revealed a surge in NMS research between 1981 and 1991, while SS research increased notably between 1993 and 1997. Active countries and journals differed between NMS and SS, with psychiatry journals predominating for NMS and pharmacology/toxicology journals for SS. Authorship analysis indicated higher multi-authored articles for NMS. Top impactful articles focused on review articles and pathogenic mechanisms. Research hotspots included antipsychotics and catatonia for NMS, while SS highlighted drug interactions and specific medications like linezolid and tramadol.

CONCLUSIONS

NMS and SS represent rare but life-threatening conditions, requiring detailed clinical and scientific understanding. Differential diagnosis and management necessitate caution in prescribing medications affecting central serotonin or dopamine systems, with awareness of potential drug interactions. International diagnostic tools and genetic screening tests may aid in safe diagnosis and prevention. Reporting rare cases and utilizing bibliometric analysis enhance knowledge dissemination and research exploration in the field of rare drug-induced medical conditions.

Serotonin Syndrome After Prolonged Remifentanil and Propofol Infusion for Craniotomy: A Case Report

Serotonin syndrome (SS) is a life-threatening condition caused by serotonergic medications. We describe a unique case of SS likely caused by prolonged exposure to propofol and remifentanil alone. A young male presented for vestibular schwannoma resection. Several hours into the case, the patient demonstrated hyperthermia and hemodynamic instability, followed by clonus, rigidity, shivering, and tachycardia after emergence. SS was diagnosed using Hunter's criteria and improved with supportive measures. While the patient endorsed a history of methamphetamine use, his urine drug screen was negative. The possibility of SS should be considered when administering propofol and remifentanil, particularly with prolonged infusions.