I have had a very challenging case of a 30 something old man found at home 
in the evening in bed by his brother having last been seen the previous 
night around midnight when he was well. He was difficult to rouse and 
uncommunicative so his brother called the ambulance.  The technician crew 
thought he was a heroin overdose and called to warn us.  The A&E SHO gave 
800 mcgs of Narcan with not a lot of improvement other than change in pupil 
size which he says were small when the patient arrived.

He had a PR 120, RR 22, BP 120/100 according to NIBP but barely palpabale 
peripherally, temp 36.5, GCS 10 (E4 V1 M5), SaO2 82 (99 on o2).  
He had some neck stiffness, chest was clear, abdo was soft.  There was one 
small area of redness on the inside of his right foot but no other signs of 
pressure sores or compartment syndromes. He was generally stiff, had trismus 
and myoclonus was very marked in the ankles.   

He had recently (weeks) attended with an overdose. His medications on this 
admission included Seroxat and Nitrazepam which had been commenced one week 
before.  We were told that there were 7 Seroxat unaccounted for by the 
ambulance crew.

Initial investigations from his blood gases revealed a K of 7.7 and a mild  
acidosis BXS -6, ph 7.243, pco2 48.4, po2 154.  ECG showed some peaking of T 
waves but qrs width was normal. Urinalysis did not reveal any blood on dip 
sticking. CXR was normal.     

I gave him 50mls 50% dextrose and 10 u insulin, 10mls Calcium gluconate and 
IV fluids. I made a diagnosis of Serotonin Syndrome based on the evidence of 
Seroxat, muscle rigidity, myoclonus, fluctuating blood pressures, altered 
mental status, diaphoresis, mutism and trismus. I then tried to find some 
Cyprohepatine.  None in our hospital pharmacy, infact none anywhere in 
Brighton (out of hours case) and eventually found some in Croydon about 1 
hour north of Brighton. I considered propranalol, largactil and GTN but 
declined based on his labile blood pressure.  

His creatinine was 234 and his CPK 2563. He developed dark urine, positive 
for blood.    

I would be interested to hear the views on what others would have done and I 
will let you know what happened next.

-------------------------------------------------
Serotonin syndrome has recently been described with SSRIs by my mates at 
Westmead hospital Sydney:
The treatment of the Serotonin Syndrome with Cyproheptadine
Graudins A, Stearman A (Andy is lurking on this list), Chan B
The Journal of Emergency Medicine 1998 Vol 16, No 4pp 615-619

This case is a lot more severe than those described by Andis Graudins et al. 
I wonder if others have seen variations of it presenting to their emergency 
departments as I know Andis has continued to collect cases since this paper 
was published as he is watching out for it.  The response to Cyproheptadine 
is reportedly quite dramatic. Having advised on this paper I am embarressed 
to say that I did not stock cyproheptatine which only costs a couple of 
pence a tablet. I now have a bottle of it and reccomend all emergency 
departments to stock it.  

Awaiting replies with interest.  Oh, and for those upset by recent clinical 
scenario postings, all, some, or none of the above story may have been 
altered from the truth !
Dr John M Ryan

Consultant & Senior Lecturer in A&E medicine
Royal Sussex County Hospital
Eastern Rd.
Brighton
UK

Ph; 00 44 1273 696955
Fax: 00 44 1273 680627

http://www.pavilion.co.uk/users/ryanj/
http://www.rsch.org.uk/rsch/rschae.htm



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