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Author: Heather S. Hernandez, MD - Oregon
Health Science University School of Medicine, Class of 2012
Introduction: Serotonin syndrome is a
potentially life-threatening disorder resulting from an excess of
serotonergic agonism with manifestations from mild to death. Often
there is a clinical triad of cognitive or mental status changes,
autonomic hyperactivity, and somatic effects such as neuromuscular
abnormalities. There is no laboratory test for serotonin syndrome.
Diagnosis is by symptom observation and thorough physical exam and
history. Treatment is aimed at withdrawal of the offending agent(s)
and supportive care until symptom resolution is achieved, without
which serotonin syndrome is fatal.
Case Presentation: We present a case of
56-year-old female with a history of fibromyalgia, depression,
migraines who in the weeks preceding her admission, had been
exhibiting episodes of confusion, visual hallucinations, and
disorientation. The patient's family also described "intermittent
twitching episodes lasting moments" during which the patient never
lost consciousness or had incontinence. Two weeks prior to
admission, she began experiencing worsening frequency and intensity
of migraine headaches with associated nausea, for which she took
ondansetron and up to 8 intra-nasal sumitriptan daily. Preceding
admission, the patient demonstrated worsening of hypomania,
agitation, diaphoresis, hyperactive bowel sounds dilated pupils,
and tachycardia with hypertension, most of which were attributed to
suspected withdrawal from opiates, though the patient denied such.
On the day of admission the patient had two witnessed episodes
consistent with seizure like activity demonstrating myoclonus, loss
of bladder control, injury to tongue, and post-ictal period.
She was admitted for further evaluation and found to have ocular
clonus, hyper-reflexia (BLE > BUE), hyperthermia to 39C, and
tremor. Complete laboratory studies were unremarkable except for a
slight metabolic acidosis. EEG demonstrated non-specific,
generalized slowing, most consistent with a post-ictal phase. Upon
review of her OTC and prescribed medications, it became apparent
the patient most likely had symptoms consistent with serotonin
The multiple offending agents were withdrawn, supportive care
with benzodiazepines and IV fluids were given, and treatment with
cyproheptadine was not required. The patient stabilized quickly and
was discharged home in her previously normal state, on
significantly fewer medications.
Discussion: Serotonergic neurons participate
the regulation of many functions including sleep, temperature,
nausea, vomiting, appetite, mood, blood pressure, and the
perception of pain. Few to all may be abnormal in serotonin
syndrome, which is often insidious in onset and easier to diagnose
in hindsight. This case also elucidates the importance of careful
history/physical, as well as obtaining a thorough medication
regimen for prescription, supplemental, and recreational
August 2012 Issue of IMpact