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Serotonin syndrome with
elevated paroxetine concentrations.
Shepherd G, Roth BA, Benitez FL.
University of Texas
South-western Medical Center, Dallas, TX 75390-8579, USA.
OBJECTIVE: To describe a case of
serotonin syndrome due to paroxetine and ethanol. CASE SUMMARY: A
57-year-old white man was brought to the emergency department one day
after ingesting paroxetine 3600 mg and a pint of hard liquor. He denied
the use of any other drug or herbal products and regular use of alcohol.
Upon arrival to the hospital, vital signs were blood pressure 188/103 mm
Hg, heart rate 114 beats/min, respiratory rate 28 breaths/min,
temperature 36.8 degrees C, and O2 saturation 96% on room air. Findings
on physical examination included dilated pupils, facial flushing,
diaphoresis, shivering, myoclonic jerks, tremors, and hyperreflexia. A
tentative diagnosis of serotonin syndrome was made. Initially,
cyproheptadine 8 mg was administered orally with no observable effect.
An additional 12 mg was given in 3 doses over 24 hours. Symptoms abated
slowly over the next 6 days, during which a thorough evaluation failed
to reveal any other potential causes for the patient's condition. Serum
paroxetine concentrations at 27.5 and 40 hours after ingestion were 1800
and 1600 ng/mL, respectively (normal 20-200 ng/mL). DISCUSSION:
Serotonin syndrome is rarely reported in patients taking only one
serotonergic medication. Although serum paroxetine concentrations have
not been shown to correlate with efficacy or toxicity, our patient's
serum paroxetine concentration was 9 times the upper end of the
therapeutic range. Cyproheptadine, which has been suggested as a
therapy, did not appear beneficial in this patient. Use of the Naranjo
probability scale indicated a probable relationship between the
serotonin syndrome and the overdose of paroxetine taken by this patient.
CONCLUSIONS: More studies are needed to better assess the role of
cyproheptadine and other serotonin antagonists in the management of the
serotonin syndrome. Regardless of the use of cyproheptadine or other
agents, attention should be paid to fluid status, decontamination, and
management of hyperthermia, agitation, and seizures.
PMID: 14742765 [PubMed - indexed for