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A RARE CASE OF SEVERE RECURRENT SEROTONIN SYNDROME

FOLLOWING A SINGLE ESCITALOPRAM OVERDOSE INGESTION

Poster · August 2023

DOI: 10.13140/RG.2.2.23652.55684

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A RARE CASE OF SEVERE RECURRENT SEROTONIN
SYNDROME FOLLOWING A SINGLE ESCITALOPRAM
OVERDOSE INGESTION
Koh Hock Peng1, Paula Teoh Suen Suen1, Nafisah Idris2, Muhamad Shazwan bin Sazali2
1Pharmacy Department, Hospital Kuala Lumpur, Malaysia; 2Emergency & Trauma Department,
Hospital Kuala Lumpur, Malaysia
1. INTRODUCTION
➢ Selective serotonin reuptake inhibitors (SSRIs) are generally much safer in overdose than tricyclic
antidepressants and monoamine oxidase inhibitors.
➢ Severe serotonin syndrome (SS) secondary to escitalopram is rare.
➢ We present a rare case of severe recurrent SS following a single escitalopram overdose ingestion.
2. CASE
➢ A 17-year-old girl with an underlying major
depressive disorder was referred to the ED from
Psychiatry Clinic after allegedly ingesting about
330mg of escitalopram due to suicidal ideation.
➢ She developed mild SS (tremors, hyperreflexia &
prolonged QTc of 620ms) and was given intravenous
(IV) magnesium sulphate.
➢ Escitalopram was discontinued.
➢ Her symptoms resolved within 24 hours, and she was
discharged from the medical ward after ~48 hours.
➢ 1 day later, she was brought to ED by her mother
due to reduce responsiveness & jerky movement of
all limbs.
➢ There was NO repeated ingestion of escitalopram.
➢ On arrival, her GCS was full but tachycardic, had a
temperature of 380C and prolonged QTc (610ms).
➢ In ED, the patient had myoclonic jerks and fitted
(general tonic-clonic) 3x before being intubated for
airway protection.
➢ Cyproheptadine was started in ED as SS symptoms
persisted despite multiple diazepam boluses and
heavily sedated with midazolam, morphine &
propofol.
➢ EEG and brain CT scan found no abnormal findings.
She was admitted to the general ICU.
➢ SS fully resolved after 5 days, and she was
extubated on day-6.
➢ Post-extubation, cyproheptadine dose was tapered
off over 2 days without any rebound in SS symptoms.
➢ Subsequently, she was discharged to the psychiatric
ward of another hospital after 11 days of
hospitalisation.
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3. DISCUSSION
• The use of SSRIs can increase
the risk of suicidal attempts,
especially among children and
adolescents.
• Escitalopram has a mean elimination
half-life of 19 hours in adolescents,
significantly shorter (about 30%)
than 27–32 hours in adults
However, it is important to note
that the pharmacokinetics data
was from small sample size
(n=11) study, where the
adolescent subjects were only
given A SINGLE DOSE of 10mg
escitalopram.
• Changes in escitalopram’s
pharmacokinetics following a
massive overdose are unknown.
• This is the first case of recurrent SS
following escitalopram ingestion, likely
due to its long half-life.
• Delayed SS had been reported in patient
with intentional fluoxetine ingestion (Little
et al. 2018). Fluoxetine’s half-life is
ranging from 96 -144 hours.
4. CONCLUSION
Severe recurrent life-threatening SS can occur
following a significant escitalopram overdose,
and the patient should be closely monitored for
a longer duration (4-5 half-lives) prior to
discharge.
References:
1. Carandang C, Jabbal R, Macbride A, Elbe D. A review of escitalopram and citalopram in child and
adolescent depression. J Can Acad Child Adolesc Psychiatry. 2011 Nov;20(4):315-24.
2. Little K, Lin CM, Reynolds PM. Delayed Serotonin Syndrome in the Setting of a Mixed Fluoxetine and
Serotonin Antagonist Overdose. Am J Case Rep. 2018 May 25;19:604-607.
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