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An Anxiety Reaction Requiring ICU Level of Care: Serotonin Syndrome<br />
Allcorn, M, D.O., PGY-3, Colyer, E, D.O.<br />
Kent Hospital, Department of Emergency Medicine, Warwick, RI<br />
INTRODUCTION: The diagnosis of serotonin syndrome can be life-threatening, as well as difficult to<br />
diagnose due to its variability of presentation, spectrum of severity, and unpredictable rate of<br />
progression. Acquiring a thorough history, developing a firm foundation of knowledge in psychiatric<br />
medications, having a high index of suspicion, early discussion with your regional Poison Control<br />
Center, and a low threshold for administration of cyproheptadine are all important aspects for the<br />
management of this devastating reaction. Today we present a case in which a 50 year-old male<br />
presented to a community hospital emergency department complaining of “the worst panic attack of<br />
my life”.<br />
CASE: A 50 yr old man presented to the emergency department with the “worst panic attack of my<br />
life.” The man stated he had been increasingly anxious over the past three days. He reported a<br />
history of anxiety and panic attacks, but stated he declined the use of benzodiazepines due to a<br />
history of alcohol abuse and subsequent benzodiazepine dependence after alcohol detoxification. He<br />
reports that earlier that evening he had been in the shower and heard his sister calling for him<br />
multiple times, but later discovered his sister was not present in the house. It was these auditory<br />
hallucinations which prompted him to come in and be evaluated. At this time, it was also elicited that<br />
the patient had recently had two changes in his medications. A few weeks prior to presentation the<br />
patient had been started on Cymbalta 60mg daily, in addition to his buspirone 15mg BID and<br />
Mirtazipine 50mg QHS. He reported that the addition of Cymbalta had been causing him GI upset and<br />
vomiting every morning, so he was subsequently instructed to attempt taking this medication at<br />
bedtime, which he began with success 5 days prior to presentation. The patient also reported a<br />
recent “pinched nerve” in his left shoulder, for which he was seen 3 days prior to presentation in the<br />
same ED and started on cyclobenzaprine (Flexeril) 10mg every 8 hours. At the time of presentation<br />
the patient had a heart rate varying from 110 up to the 140. His presenting blood pressure was<br />
162/97, but at the time of initial exam by the resident, he was normotensive. He was afebrile, and<br />
aside from his tachycardia he had no abnormal findings on physical exam. He received an IV fluid<br />
bolus, but refused benzodiazepines to treat his anxiety due to his history. Therefore, he was initially<br />
given 12.5mg quitiapine IV to treat this symptom. He had no resolution of his anxiety approximately<br />
30 minutes after this, and remained tachycardic in the 130’s. The diagnosis of serotonin syndrome<br />
was brought up discussion, but his only sign of autonomic instability was his tachycardia and he had<br />
no clonus or altered mental status. Of note, there was still some suspicion, despite his adamant<br />
refusal, that this was alcohol withdrawal. After no improvement with quitiapine, he agreed to 1mg of<br />
IV lorazepam. Approximately 30 minutes after this, he became more altered and developed<br />
spontaneous clonus. At that time, the diagnosis was made and the patient was treated with a loading<br />
dose of cyproheptadine, admitted to the ICU, and the regional Poison Control Center was consulted,<br />
who agreed with this plan. Once in the ICU, the patient’s temperature rose to 39ºC and he became<br />
more altered, requiring sedation and mechanical ventilation. He was continued on cyproheptadine<br />
until his fever and clonus resolved, on ICU day 4.<br />
DISCUSSION: As stated above, knowledge of the pharmacology of psychiatric medications is<br />
essential. While none of the patient’s medications were specifically SSRI’s, all three have<br />
serotonergic properties. Cyclobenzaprine is structurally similar to TCA’s, which have weak<br />
serotonergic properties, while Cymbalta (which had been being thrown up, but was now tolerated with<br />
bedtime dosing) and buspirone both also carry weak serotonergic properties. A thorough history<br />
noting the addition of two of these medications should have, and did, raise the suspicion of serotonin<br />
syndrome. However, as previously mentioned serotonin syndrome is a spectrum of clinical<br />
presentation and should have been suspected at the earliest signs of autonomic instability,<br />
hyperreflexia, or altered mental status. This case also emphasizes the importance of listening to the<br />
patient. His anxiety, disorientation, and delirium were early indicators of the impending development<br />
of serotonin syndrome, not alcohol withdrawal.