Sangeetha Isaac, MD
North Alabama Medical Center
Florence, Alabama
Disclosure information not submitted.
Mohammed Afraz Pasha, MD,
Internal Medicine Resident
North Alabama Medical Center
Florence, Alabama
Disclosure information not submitted.
Maged Ghaly, MD
Internal Medicine Resident
North Alabama Medical Center, Alabama, United States
Disclosure information not submitted.
Shalom Isaac, MBBS
Medical Registrar
Christian Medical College, Vellore, Tamil Nadu, India
Disclosure information not submitted.
Amos Lal, MBBS, FACP (he/him/his)
Fellow, Critical Care Medicine
Mayo Clinic
Rochester, Minnesota
Disclosure information not submitted.
Saquib Anjum, MD
Associate Program Director
North Alabama Medical Center, United States
Disclosure information not submitted.
Title: Complex partial status epilepticus precipitated by serotonin syndrome
Case Report Body: INTRODUCTION: Serotonin Syndrome(SS) precipitating seizures with documented epileptic activity on EEG is rarely reported. We describe a patient with status epilepticus precipitated in the setting of serotonin syndrome following overdose with venlafaxine and tianeptin.
Description: A 34-year-old lady was brought to the emergency room in confused state with incessant vomiting, last well-known time was 14 hours prior to the presentation. Medical history was notable for recently diagnosed depression managed with venlafaxine.
She was afebrile 97.8’F, hemodynamically stable, tachypneic(22/min) and hypoxic 90% on room air). Her GCS was 9 E2V3M4), pupils dilated at 4 mm, with sluggish response to light. Neurological examination was notable for myoclonic jerks involving all 4 extremities. Fundoscopy was unsuccessful in light of the myoclonic jerks. She did not have any rash.
Laboratory investigations showed neutrophil predominant leukocytosis 25600/mm3. ABG showed compensated metabolic acidosis with pH 7.42, PCO2 22.7, PO2 118, bicarbonate 14.8 and lactate 6.2. CT and MRI head was unremarkable. Lumbar puncture was attempted but unsuccessful due to persistent myoclonic activity. Urine toxicology screen was positive for cannabinoids. She was initiated on broad spectrum antibiotics, acyclovir and dexamethasone.
Considering possibility of SS, empiric cyproheptadine was given. She was treated with lorazepam and levetiracetam. EEG on presentation showed presence of spike-wave complexes in the frontal lobe indicative status epilepticus.
After initiation of appropriate treatment, in the next 24 hours her mental status returned to baseline; on further questioning she admitted to taking tianeptine over-the-counter for insomnia, along with venlafaxine. Repeat EEG in 24 hours demonstrated background slowing with burst suppression. With negative cultures and downtrending leukocytosis, antibiotics were deescalated. She was educated on drug interactions, and advised to continue levetiracetam with close follow up.
Discussion: SS is diagnosed clinically with Hunter Criteria, classical triad being cognitive, autonomic, and neuromuscular dysfunction. Imbalance of glutamate excess and inadequate gamma aminobutyric acid as a result of SS provokes seizures. SS can be prevented by educating patients on potential drug interactions.