SEROTONIN SYNDROME IN A PATIENT WITH DUAL DIAGNOSIS-CASE STUDY

Mina Cvjetković Bošnjak; Željko Bibić; Dušan Kuljančić

doi:10.5937/sanamed0-45500

Mina Cvjetković Bošnjak 1. Faculty of medicine, University in Novi Sad, Novi Sad; 2. Clinic for Psychiatry, University Clinical Center of Vojvodina in Novi Sad, Novi Sad, Serbia
Željko Bibić General hospital Vrbas, Vrbas
Dušan Kuljančić 1. Faculty of medicine, University in Novi Sad, Novi Sad, Serbia; 2. Clinic for Psychiatry, University Clinical Center of Vojvodina in Novi Sad, Novi Sad, Serbia

DOI: https://doi.org/10.5937/sanamed0-45500

Keywords: serotonin syndrome-risk, treatment, SSRI, SNRI

Abstract

Introduction: Serotonin syndrome is a rare but potentially life-threatening condition. In most cases, this complication is caused by taking two serotonergic medications simultaneously, leading to excessive serotonin concentration in the body. Selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), as well as irreversible monoamine oxidase inhibitors (MAOIs) and their combination with other serotonergic substances, are associated with symptoms of serotonin syndrome.

Case study: A patient who was prescribed sertraline (an SSRI) for a depressive episode suffered fractures in a traffic accident during the treatment, and tramadol was prescribed for her pain. Since both drugs tend to increase serotonin levels in the body, a complication in the form of serotonin syndrome developed. With timely recognition and treatment, the symptoms of serotonin syndrome resolved without lasting consequences.

Conclusion: Numerous drugs and substances can induce serotonin syndrome, often in combination with antidepressants. Therefore, it is of great importance that doctors are aware of comorbid conditions that necessitate the use of the mentioned drugs in order to prevent serotonin syndrome. If it does occur, adequate and successful treatment is crucial.

References

1.Fricchione GL, Beach SR, Huffman JC, Bush G, Stern TA. Life-threatening conditions in psychiatry: catatonia, neuroleptic malignant syndrome and serotonin syndrome.In:Stern TA, Fava M, Wilens TE, Rosenbaum JF, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 2nd ed., 2015.

2.Meehan TJ. Care of the poisoned patient. In: Walas RM, Hockberger RS, Gausche Hill M, eds Rosens Emegency Medicine: Concepts and Clinical Practice. 10^th.ed. Philadelphia PA: Elsevier; 2023:chap 135. doi:10.5070/M561051830.

3.Sporer KA. The Serotonin Syndrome. Implicated drugs, pathophysiology and management. Drug Saf. 1995;13 (2):94-104. doi: 10.2165/00002018-199513020-00004.

4.Dunkley EJ, Isbister GK, Sibri HD, Dawson AH,Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. OJM. 2003;96 (9):635-42.doi:10.1093/qjmed/hcg109

5.Gillman PK. The serotonin syndrome and its treament. J. Psychopharmacol. 1999(Oxford);13(1):100-9.doi:10.1177/026988119901300111.

6.Tormoehlen LM, Rusyinak DE. Neuroleptic malignant syndrome and serotonin syndrome. Handb Clin Neurol. 2018;157:663-75.doi:10.1016/8978-0-444-64074-1.00039-2

7.Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine. J Emerg Med. 1998;16(4):615-9.doi:10.1016/S0736-4679(98)00057-2

8.Houlihan DJ. Serotonin syndrome resulting from coadministration of tramadol, venlafaxine and mirtazapine. Ann Pharmacother.2004;38(3):411-3.doi:10.1345/anh.1D344.

9. Rickli A, Liakoni E, Hoener MC, Liechti ME. Opioid-induced inhibition of the human 5-HT and noradrenaline transporters in vitro: link to clinical reports of serotonin syndrome. Br J Pharmacol. 2018;175(3):532-43. doi: 10.1111/bph.14105.

10..Frank C. Recognition and treatment of serotonin syndrome. Can Fam Physician. 2008;54(7):988-92.

11.Sun-Edelstein C, Tepper SJ, Shapiro RE. Drug-induced serotonin syndrome: a review. Expert Opin Drug Saf. 2008;7(5):587-96. doi: 10.1517/14740338.7.5.587.

12. Chan BSM Graudins A,Whyte IM, Dawson AH, Braitberg G, Duggin GG. Serotonin syndrome resulting from drug interaction. Med J Aust.1998:169(10): 523-5. doi:10.5694/j.1326-5377.1998tb123399.x.

13. Foong AL, Grindrod KA, Patel T, Kellar J. Demystifying serotonin syndrome (or serotonin toxicity). Can Fam Physician. 2018;64(10):720-7.

14.Scotton WJ, Hill L, Williams AC, Barnes N. Serotonin Synddrome: pathophysiology, clinical features, management and potentional future direction. Int J Tryptophan Res. 2019;12:11786491987395;doi:10.1177/117864691987395.

15.Arora B, Kannikeswaran N. The Serotonin Syndrom-the need for physicians awareness. Int J Emerg Med. 2010;3(4):373-7,doi:10.1007/s 12245-010-0195-7.

16.Levin TT, Cortes-Ladino A, Weiss M, Palomba ML. Life-threatening serotonin toxicity due to a citalopram-fluconazole drug interaction:case reports and discussion. Gen Hosp Psychiatry. 2008;30(4):372-7. doi: 10.1016/j.genhosppsych.2008.03.008.

17.Morarasu BC,Coman AE, Bolonga C, Lionte C, Petris OR,Ceasovschih A et al.Recognition and management of Serotonin Toxidrome in the Emergency Department-case based review. J Pers Med. 2022;12(12):2069. doi:10.3390/jpm12122069.

18.Malcolm B, Thomas K. Serotonin toxicity of serotonergic psychodelics. Psychopharmacology. 2022;239(6):1881-91. doi:10.1007/s00213-021-05876-x.

19.Buckley N,Dawson AH, Isbister GK. Serotonin syndrome. BMJ.2014;348:g1626. doi:10.136/bmj.g.1626

20.Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352 (11):1112-20. doi:10.1056/NEJMRa041867

21.Iqbal MM, Basil MJ, Kaplan J, Iqbal T. Overview of serotonin syndrome. Ann Clin Psychiatry.2012;24(4):310-8.

22. Prakash SA. Diagnostic confusion between Serotonin syndrome and Neu5roleptic malignant syndrome. Am J Emerg Med. 2021:43;272-3. doi:10.1016/J.AJEM2020.06.046.