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Prakash S, Gupta R, Raval MM, Tibrewal C. Serotonin syndrome presenting as acute dizziness with supine hypertension and orthostatic hypotension. BMJ Case Rep 2024; 17:e260229. [PMID: 38627042 PMCID: PMC11029266 DOI: 10.1136/bcr-2024-260229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Serotonin syndrome (SS) is a drug-induced clinical syndrome characterised by a combination of cognitive, neuromuscular and autonomic dysfunctions. The symptoms may include mild non-specific symptoms such as tremors and diarrhoea to coma and sudden death. Herein, we describe a case of SS in which acute dizziness was associated with supine hypertension and orthostatic hypotension. A man in his mid-30s had a 10-month history of anxiety, depression and chronic tension-type headache. He had been on amitriptyline (25 mg daily) and sertraline (50 mg daily). Increment of sertraline (75 mg daily) and amitriptyline (75 mg daily) and the addition of tramadol led to the development of acute severe dizziness. Physical examinations demonstrate supine hypertension and orthostatic hypotension. He also met the diagnostic criteria of SS. The administration of cyproheptadine provided a complete response to dizziness, supine hypertension, orthostatic hypotension and other clinical features of SS.
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Affiliation(s)
- Sanjay Prakash
- Neurolgy, SBKS Medical Institute and Research Centre, Vadodara, India
| | - Ravisha Gupta
- Medicine, Smt BK Shah Medical Institute & Research Centre, Waghodia, Gujarat, India
| | - Maitree M Raval
- Medicine, Smt BK Shah Medical Institute & Research Centre, Waghodia, Gujarat, India
| | - Charu Tibrewal
- Medicine, The Gujarat Research & Medical Institute, Ahmedabad, Gujarat, India
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Prakash S, Patel H, Kumar S, Shah CS. Cyproheptadine in serotonin syndrome: A retrospective study. J Family Med Prim Care 2024; 13:1340-1346. [PMID: 38827706 PMCID: PMC11142004 DOI: 10.4103/jfmpc.jfmpc_652_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 06/04/2024] Open
Abstract
Objective Serotonin syndrome (SS) is an iatrogenic life-threatening condition caused by serotonergic agents. The treatment for SS involves the administration of a serotonin antagonist (cyproheptadine). However, the dosing schedule for cyproheptadine is not uniform in the literature. Methods We retrospectively evaluated 23 adult patients (>18 years) admitted to the Neurology Department and met the Hunter criteria for SS. Results The mean age was 35.2 years, and 52% were female. Ten patients were managed in the intensive care unit (ICU), whereas thirteen patients were admitted to the ward. Hyperreflexia was the most common clinical feature (100%), followed by clonus (91%), tachycardia (83%), and tremor (83%). Other common clinical features were rigidity (65%), increased bowel sound (61%), diaphoresis (48%), fever (43%), hypertension (39%), and myoclonus (30%). All but one patient received two or more serotonergic drugs. Tramadol was the most common serotonergic agent (39%), followed by sodium valproate (21%), and amitriptyline (21%). Cyproheptadine was administered to all patients. All patients admitted in the ICU received a loading dose of 12 mg followed by 2 mg every 2 h for at least 24 h. All patients admitted to the ward were given 4 mg of cyproheptadine three times each day. Every patient showed at least some response to cyproheptadine within 24 h. The total doses of cyproheptadine and the length of treatment differed between patients. Conclusion Any response to cyproheptadine at a therapeutic dose within 24 h, even a partial one, could be a diagnostic indicator of the existence of SS.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, India
| | - Harsh Patel
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, India
| | - Sunil Kumar
- Department of Medicine, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Chetsi S. Shah
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, India
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Naismith RT, Cohen JA, Bar-Or A, Comi G, Selmaj KW, Hartung HP, Sheffield JK, Krakovich A, Tatosian D, Cheng CY, Reardon J, Khaychuk V, Riolo JV, Silva D, Cree BAC. Concurrent administration of serotonergic antidepressants and ozanimod in participants with relapsing multiple sclerosis from the open-label extension DAYBREAK trial. Mult Scler 2024; 30:177-183. [PMID: 38130041 PMCID: PMC10851643 DOI: 10.1177/13524585231216854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Monoamine oxidase (MAO) inhibitors can interact with selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs). There is clinical interest surrounding use of ozanimod with SSRIs/SNRIs because the major metabolites of ozanimod are weak inhibitors of MAO-B in vitro. OBJECTIVE To evaluate the incidence of treatment-emergent adverse events (TEAEs) potentially related to serotonin accumulation (SA) during concomitant ozanimod and SSRI/SNRI use by performing analyses of data from an open-label, oral ozanimod 0.92 mg trial (DAYBREAK; NCT02576717). METHODS SA narrow (serotonin syndrome, neuroleptic malignant syndrome, and hyperthermia malignant) and broad (terms potentially associated with SA) MedDRA v24.0 searches were performed using TEAE data from participants with relapsing multiple sclerosis who entered DAYBREAK from phase 3 studies (cutoff February 1, 2022). Incidences of TEAEs matching terms from each search were stratified by SSRI/SNRI use. RESULTS Of 2257 DAYBREAK participants, 274 (12.1%) used an SSRI/SNRI. No participants had TEAEs matching the SA narrow search terms. There was no significant difference in the percentage of participants with ⩾1 TEAE matching the SA broad search for those on versus off SSRIs/SNRIs (on: 12.4%, n = 34/274; off: 15.6%, n = 310/1982, nominal p = 0.1630). CONCLUSION MedDRA searches showed no increase in TEAEs potentially associated with SA with concomitant SSRI/SNRI and ozanimod use.
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Affiliation(s)
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Giancarlo Comi
- Vita-Salute San Raffaele University and Casa di Cura Igea, Milan, Italy
| | - Krzysztof W Selmaj
- Center for Neurology, Łódź, Poland
- Collegium Medicum, Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Palacký University Olomouc, Olomouc, Czech Republic
| | | | | | | | | | | | | | | | | | - Bruce AC Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Prakash S, Patel H, Shah CS. Medication-overuse headache overlapping with serotonin syndrome. BMJ Case Rep 2024; 17:e256464. [PMID: 38176752 PMCID: PMC10773342 DOI: 10.1136/bcr-2023-256464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
Serotonin syndrome (SS) is an iatrogenic, drug-induced clinical syndrome caused by an increase in the intrasynaptic concentration of serotonin. Serotonin plays a significant role in the pathophysiology of migraines. Upregulation of 5-HT2A receptors is found in medication-overuse headache (MOH). Several migraine medications, both preventative and abortive drugs, act on serotonin receptors. We report two patients with chronic migraine who developed MOH. Besides headache, patients had frequent attacks of dizziness, restlessness, irritability, insomnia, excessive sweating, abdominal discomforts and tremors. These symptoms were suggestive of withdrawal headache. However, on physical examinations, we elicited hyperreflexia, hypertonia, clonus, tachycardia, hypertension, mydriasis and hyperactive bowel sound. Both patients also met the criteria for SS. Cyproheptadine was started. All features, including headaches, got better after cyproheptadine administration within 24 hours. In 7 days, there was practically total improvement. Both patients continued to take cyproheptadine as a preventative medicine, and migraine frequency was under control.
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Affiliation(s)
- Sanjay Prakash
- Neurolgy, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Harsh Patel
- Neurolgy, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Chetsi Sudhir Shah
- Neurolgy, SBKS Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
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Badar A. Serotonin syndrome: An often-neglected medical emergency. J Family Community Med 2024; 31:1-8. [PMID: 38406216 PMCID: PMC10883429 DOI: 10.4103/jfcm.jfcm_236_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/24/2023] [Accepted: 12/06/2023] [Indexed: 02/27/2024] Open
Abstract
Optimum serotonin level in the serotonergic synapses of the central nervous system (CNS) is related to mood, behavior, and sleep. Serotonin syndrome (SS) is a rare yet very dangerous adverse effect resulting from increased serotonin in CNS. The diagnosis of SS is based on the presence of clinical symptoms, which can include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle rigidity, tremors, sweating, and diarrhea. SS is invariably caused by inadvertent use of serotonergic medicines. There is an ever-growing list of medicines that are associated with the risk of SS. Some of the common classes of drugs that can contribute to the development of SS include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, stimulants (e.g., amphetamines and cocaine), lithium, opioids, drugs used for recreational purposes like ecstasy Methylenedioxymethamphetamine (MDMA), and some herbal supplements (e.g., St. John's Wort). SS can occur when these medications are taken alone or in combination, especially when a new medication is added, or the dose of an existing medication is changed. The management of SS typically involves discontinuing the use of the substance that caused the excess serotonin levels and providing supportive care, such as intravenous fluids and electrolytes. In severe cases, benzodiazepines may be used to control agitation and muscle rigidity, while serotonin antagonists, such as cyproheptadine, may be used to reduce serotonin levels. The literature review points to a general unawareness among physicians about the condition or drugs associated with it. Consequently, this potentially fatal condition is overlooked. There is a need for regular information updates and reminders to all those who prescribe medications to the patients.
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Affiliation(s)
- Ahmed Badar
- Department of Physiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Poian LR, Chiavegatto S. Serotonin Syndrome: The Role of Pharmacology in Understanding Its Occurrence. Cureus 2023; 15:e38897. [PMID: 37309350 PMCID: PMC10257984 DOI: 10.7759/cureus.38897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
Serotonin syndrome (SS) is a potentially fatal adverse drug reaction characterized by an exaggerated increase in serotonergic activity in the central and peripheral nervous systems. It presents a constellation of signs and symptoms related to behavioral changes, neuromuscular excitability, and autonomic instability. These symptoms can occur in both mild and severe forms. SS can be triggered by the therapeutic use of a drug that increases serotonin (5-HT) availability in the synaptic cleft or by the co-administration of two or more drugs that provide this increase. With the escalating use of antidepressants by the world's population, this adverse reaction may be more recurrent. However, SS is often overlooked by patients or not diagnosed by doctors. This review aims to improve awareness about SS and provide a pharmacological perspective to explain its occurrence. Evidence shows that other neurotransmitters may also be involved with the pathology of SS. Furthermore, SS and neuroleptic malignant syndrome (NMS) seem to be part of the same pathological spectrum, especially in atypical NMS cases. The emergence of the syndrome's symptoms may be closely related to pharmacokinetic and/or pharmacodynamic polymorphisms that lead to an increase in the 5-HT available to or 5-HT signaling by specific receptors, thus constituting an important area for future investigations.
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Affiliation(s)
- Leila R Poian
- Department of Pharmacology, Biomedical Sciences Institute, University of Sao Paulo (ICB-USP), Sao Paulo, BRA
| | - Silvana Chiavegatto
- Department of Pharmacology, Biomedical Sciences Institute, University of Sao Paulo (ICB-USP), Sao Paulo, BRA
- Department of Psychiatry, Institute of Psychiatry, University of Sao Paulo Medical School (FMUSP), Sao Paulo, BRA
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Prakash S, Rathore C, Rana K. Serotonin Syndrome: A Syndrome on Syndrome. Ann Indian Acad Neurol 2021; 24:430-432. [PMID: 34447015 PMCID: PMC8370158 DOI: 10.4103/aian.aian_421_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/15/2020] [Accepted: 05/17/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Kaushik Rana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
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Prakash S, Lodha D, Rawat KS. Coexistence of serotonin syndrome and neuroleptic malignant syndrome: does it exist? BMJ Case Rep 2021; 14:e241578. [PMID: 34400419 PMCID: PMC8370549 DOI: 10.1136/bcr-2021-241578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 11/04/2022] Open
Abstract
We report a 21-year-old man with bipolar disorder who was on a stable dose of escitalopram and risperidone. Tramadol and cough syrup (dextromethorphan) were added for his recent attack of upper respiratory tract infection. However, he developed various neurological symptoms. Haloperidol and ondansetron were added after hospitalisation. However, his condition deteriorated. A diagnosis of serotonin syndrome (SS) was made, and cyproheptadine was started. Cyproheptadine provided relief in most of the symptoms within 48 hours except for the presence of fever and rigidity. The addition of bromocriptine provided a complete resolution of the symptoms. We considered the presence of both SS and neuroleptic malignant syndrome (NMS) in this case. There are four similar cases in the literature. We discussed a diagnostic and therapeutic approach for patients who are on both serotonergic agents and neuroleptics and develop SS-like or NMS-like clinical features.
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Affiliation(s)
- Sanjay Prakash
- Neurolgy, SBKSMI&RC, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
| | - Deepali Lodha
- Department of Medicine, Smt BK Shah Medical Institute and Research Centre, Waghodia, Gujarat, India
| | - Kalu Singh Rawat
- Neurolgy, Smt BK Shah Medical Institute and Research Centre, Waghodia, Gujarat, India
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Prakash S, Rathore C, Rana K, Patel H. Antiepileptic drugs and serotonin syndrome- A systematic review of case series and case reports. Seizure 2021; 91:117-131. [PMID: 34153897 DOI: 10.1016/j.seizure.2021.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/12/2022] Open
Abstract
Serotonin syndrome (SS) is a drug‑induced, potentially fatal, clinical syndrome resulting from drugs that have serotonergic properties. Several antiepileptic drugs (AEDs) are known to have serotonergic properties and it can be hypothesized that such AEDs can cause SS. This study aims to review the literature on SS in patients receiving AEDs. We performed a systematic review of Scopus and MEDLINE/PUBMED for case reports and case series of SS where patients had received at least one AED at the onset of symptoms. The cases published in the English literature between 1 January 1991 and 1 April 2021 were included. Initial search identified 1263 articles of which 63 (76 patients) were included in the final analysis. Most of the included cases (53 cases, 70%) have been published in the last 10 years. The mean age of the 76 patients was 40.6 ± 17.8 years, and 51% of cases were females. These patients had been exposed to a total of 8 different types of AEDs. Valproic acid was the most common drug (29, 38%), followed by lamotrigine (22, 29%), gabapentin (16, 21%), pregabalin (seven, 9%), topiramate (five, 7%) and carbamazepine (two, 3%). There has been one case each with phenytoin and oxcarbazepine. Seven (9%) patients received more than one AEDs. Most patients (67, 88%) also received other serotoninergic agents. Only nine (12%) patients were on AEDs alone. The most common clinical condition for using AEDs was psychiatric disorders (36 patients, 47.3%), followed by migraine (17, 22.4%), other painful conditions (15, 19.7%), epilepsy (7, 9.2%), and perioperative conditions (8, 10.5%). Death was reported in two patients. We suggest that AEDs, because of their serotonergic properties, may induce SS, especially in patients who are on another serotonergic agent.
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Affiliation(s)
- Sanjay Prakash
- Professor and Head, Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India.
| | - Chaturbhuj Rathore
- Professor, Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India.
| | - Kaushik Rana
- Assistant Professor, Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India
| | - Harsh Patel
- Senior Resident, Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India.
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Prakash S, Rathore C, Rana K. The prevalence of serotonin syndrome in an intensive care unit: A prospective observational study. J Crit Care 2020; 63:92-97. [PMID: 33621893 DOI: 10.1016/j.jcrc.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/11/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE In spite of life-threatening nature of serotonin syndrome (SS), it remains an under-diagnosed condition. The availability of epidemiological data about SS, especially in the ICU setting, may help physicians make early diagnoses and interventions. MATERIALS AND METHODS This was a 6-month prospective study in a medical ICU of a tertiary hospital to find out the prevalence of SS. All consecutive adult patients admitted to the medical ICU were evaluated to see if they fulfilled the Hunter criteria of SS. Patients who met the Hunter criteria were evaluated further for other details. RESULTS Overall, 309 patients were identified of which 24 (7.8%) met the Hunter criteria. The mean age was 52.4 years, and 75% were male. Most patients received two or more serotonergic drugs. Ondansetron was the most common serotonergic drug (58%), followed by tramadol (38%), and cough syrup (dextromethorphan or chlorpheniramine, 21%). None of the patients received a diagnosis of SS by the treating physicians. Chronic obstructive pulmonary disease exacerbation with respiratory failure and metabolic encephalopathy were the two most common admission diagnoses (17% each). Twenty-two patients received cyproheptadine. There were no fatalities. CONCLUSION SS is not uncommon in the ICU setting. There is a need to increase awareness among physicians.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara 391760, Gujarat, India.
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara 391760, Gujarat, India.
| | - Kaushik Rana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara 391760, Gujarat, India
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Prakash S, Rathore C, Kaushikkumar R. Posterior reversible encephalopathy syndrome in a patient with serotonin syndrome. BMJ Case Rep 2020; 13:e236450. [PMID: 33298478 PMCID: PMC7733117 DOI: 10.1136/bcr-2020-236450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
Serotonin syndrome (SS) is a drug-induced clinical syndrome, characterised by a triad of cognitive impairment, autonomic hyperactivity and neuromuscular abnormalities. Hypertension, one of the common autonomic manifestations in SS, may lead to lead to several life-threatening conditions. Herein, we report a case of SS who had posterior reversible encephalopathy syndrome (PRES) because of high blood pressure.A young male with a 5-month history of chronic tension-type headache and depression had been receiving amitriptyline and paroxetine. Increment of paroxetine led to the development of various new clinical features, fulfilling the Hunter criteria of SS. MRI brain revealed high-signal intensity lesions on T2 fluid-attenuated inversion recovery, and T2-weighted imaging in the posterior regions of the occipital, parietal, temporal and cerebellum lobes, suggestive of PRES. The patient responded to cyproheptadine. Autonomic hyperactivity, due to SS, is the most likely explanation of this association.
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Affiliation(s)
- Sanjay Prakash
- Neurology, Smt BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Waghodia, Gujarat, India
| | - Chaturbhuj Rathore
- Smt BK Shah Medical Institute and Research Centre, Vadodara, Gujarat, India
| | - Rana Kaushikkumar
- Neurology, Smt BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Waghodia, Gujarat, India
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Prakash S, Rathore C, Rana K, Prakash A. Fatal serotonin syndrome: a systematic review of 56 cases in the literature. Clin Toxicol (Phila) 2020; 59:89-100. [PMID: 33196298 DOI: 10.1080/15563650.2020.1839662] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Serotonin syndrome (SS) is a drug-induced potentially life-threatening clinical condition. There is a paucity of data on the risk factors, clinical course, and complications associated with fatal SS. OBJECTIVE To characterize the epidemiological profile, clinical features, and risk factors associated with fatal SS through a systematic review. METHODS We performed a systematic review of MEDLINE and Google Scholar for case reports, case series, or cohort studies of fatal SS. RESULTS Initial database search identified 2326 articles of which 46 (56 patients) were included in the final analysis. The mean age was 42.3 years (range 18-87 years) with female predominance (57%). North America and Europe constitute 80% of the reported fatal SS. The symptoms evolved very rapidly, within 24 h after the administration of serotonergic drugs in 59% of the cases. Fever (61%) was the most common symptom, followed by seizure (36%) and tremors (30%). The mean temperature in the reported cases (25 patients) was 41.6 ± 1.3 °C (range 38.3-43.5 °C). SS was reported to occur with the maintenance dosage of serotonergic agents, after initiation of the drug for the first time, and addition of the drugs for the development of another unrelated illness. Creatine kinase (CK) activities were elevated (>3 times of the upper limit of normal) in eighteen patients, and it was very high (>25,000 IU/L) in four patients. Presence of high grade fever, seizures, and high CK activities may be associated with severe SS. Nine patients (16%) received 5-HT2A antagonists as a therapy. About 50% of patients died within 24 h of the onset of symptoms. CONCLUSIONS While fatal SS is rare, frequently observed features include hyperthermia, seizures, and high CK activities. Cyproheptadine use appears infrequent for these patients.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Kaushik Rana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Anurag Prakash
- Parul Institute of Medical Sciences & Research, Parul University, Waghodia, Vadodara, India
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Prakash S. Comment on Serotonin toxicity from isolated bupropion overdoses. Clin Toxicol (Phila) 2020; 58:1359. [PMID: 32544010 DOI: 10.1080/15563650.2020.1776872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Sanjay Prakash
- Department of Neurology Smt. B. K. Shah Medical Institute and Research Centre, Vadodara Gujarat, Waghodia, India
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Prakash S, Rathore C, Rana K. Knowledge, Attitude, and Practice (KAP) Study on Serotonin Syndrome Among Neuro Physicians. Ann Indian Acad Neurol 2020; 23:638-643. [PMID: 33623264 PMCID: PMC7887483 DOI: 10.4103/aian.aian_603_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background and Aims: Serotonin syndrome (SS) is a highly underdiagnosed drug-induced clinical syndrome. Under diagnosis is partly due to the unawareness of this syndrome by physicians. The aim of this study is to assess the knowledge, attitude and practice of SS among neuro physicians in India. Methods: A cross-sectional survey using a self-administered questionnaire was carried out among neuro physicians in India. Neuro physicians attending the various neurological conferences and meetings were approached to participate in the study. Result: A total of 150 neuro physicians responded to the survey. About 31% of participants correctly recognized the criteria for SS. Only 17% of the neuro physicians considered clonus as the most important feature in SS. Very few physicians correctly identified serotonergic agents causing serotonin syndrome. Similarly, a very low percentage of neuro physicians correctly identified the drugs used in the management of SS. Drugs used for the treatment of SS were incorrectly recognized as drugs causing SS. Clonus is the most specific feature for SS. However, examination for clonus is not a routine phenomenon in clinical practice among neuro physicians. Conclusion: This study shows great deficiencies in all domains of SS among neuro physicians. There is a need to make every doctor aware of SS by educational programs.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Kaushik Rana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
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