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Serotonin Syndrome and Neuroleptic Malignant Syndrome: Pearls & Pitfalls

Why do we care about this disease? We care about this because the medical community often misses it. In a previously published survey study, as many as 85% of physicians didn’t know what SS was. While that number is probably much better these days, SS still often goes unrecognized. At least part of the reason why we miss this disease is due to the fact that mild cases can present with non-specific symptoms such as tremors, diarrhea, and tachycardia.4 Often when SS starts advancing from the mild into the moderate category, we may inadvertently treat the condition with more serotonergic medications, further precipitating decline.10 Most importantly, it can be deadly

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 EM@3AM: Serotonin Syndrome

Consider with history of polypharmacy, antidepressant, or opioid use, Presentation has fast onset and resolution, Clonus is a key physical exam finding, Hyperthermia, seizures, and rhabdomyolysis indicate severe serotonin syndrome, Treatment is supportive, targeting hyperthermia and agitation.

 NMS Versus Serotonin Syndrome

Distinguishing between neuroleptic malignant syndrome and the serotonin syndrome seems to be a recurring problem for emergency physicians, although differentiating between them is fundamentally less complicated than many people realize.

 Paucis Verbis: Serotonin syndrome

Fortunately, there’s a nice algorithm (Hunter’s decision rule) which helps you decide whether it is serotonin syndrome or not.

 Serotonin Syndrome: Consider in the Older Patient with Altered Mental Status

However, as with most classic triads, all three components are not present in the majority of patients. The vague and variable presenting symptoms make this a particularly difficult diagnosis in the elderly, who may have underlying dementia. It is a diagnosis you will miss if you don’t have it in the back of your mind.

Articles of Interest

A Mix of Medicines That Can Be Lethal

Now, with the enormous rise in the use of serotonin-enhancing antidepressants, often taken in combination with other drugs that also raise serotonin levels, emergency medicine specialists are trying to educate doctors and patients about this not-so-rare and potentially life-threatening disorder.

Annals of B-Pod: Serotonin Syndrome

Serotonin syndrome is a condition caused by increased serotonergic activity in the central nervous system. Patients may present with a broad range of symptoms such as anxiety and tremor in mild cases, or altered mental status, cardiovascular compromise, and seizures in severe cases. Mild serotonin syndrome can occur as a side effect of normal medication use for depression or anxiety. Moderate to severe cases, however, are often due to medication interactions or intentional overdose, and can quickly become life threatening, making recognition and prompt treatment of this condition important for the emergency physician.

How does MDMA kill?

The main action of MDMA in the brain is an increase in serotonin, which among other things is responsible for regulating pro-social behaviour, empathy and optimism. This is why people who have taken MDMA feel connection with and positivity towards others. But too much serotonin can result in “serotonin syndrome”. It typically occurs when other drugs that also raise serotonin levels (other stimulants, antidepressants) are taken together with MDMA.

Serotonin Syndrome

Many commonly used medications have proven to be the culprits of serotonin syndrome. Proper education and awareness about serotonin syndrome will improve the accuracy of diagnosis and promote the institution of the appropriate treatment that may prevent significant morbidity and mortality.

Serotonin Syndrome (Part 2) - What Causes It?

Serotonin syndrome is not an idiopathic drug reaction, but the result of excess serotonin in the nervous system. Although selective serotonin reuptake inhibitors (SSRIs) are most commonly implicated, there are other medications encountered in the Emergency Department that can also play a role in serotonin syndrome.

Serotonin Syndrome and the Libby Zion Affair

In over a decade of legal proceedings that followed, it became apparent that most physicians were unaware of serotonin toxicity and of the potentially fatal interaction of meperidine and monoamine oxidase inhibitors.

Serotonin Syndrome CCC

Serotonin syndrome results from drug-induced over-stimulation of serotonin receptors in the CNS and is characterized by a triad of CNS dysfunction, autonomic disturbance and neuromuscular effects.

Serotonin Syndrome in the Emergency Department

Serotonin syndrome (SS) is an often undiagnosed and potentially life-threatening adverse drug reaction caused by excessive activation of postsynaptic serotonin receptors. The actual incidence of SS is difficult to measure because so many cases go unrecognized.

Serotonin Syndrome: 7 Things You Need to Know

Early reports of serotonin overload occurred in the 1950s with antidepressants called monoamine oxidase inhibitors (MAOIs). When new drugs called selective serotonin reuptake inhibitors (SSRIs) became widely used to fight depression, reports of serotonin syndrome increased.

The Edge: Serotonin Syndrome, Neuroleptic Malignant Syndrome, and Malignant Hyperthermia

Have you ever had a patient with altered mental status, perhaps some myoclonus and even fever, whom you were pretty sure had some type of toxicology issue going on but just weren’t sure what it might be? Perhaps you see they’re on an antidepressant or an antipsychotic. Maybe you even remember something about serotonin syndrome or neuroleptic malignant syndrome but can’t for the life of you remember which is which.

The Serotonin Story

Most people have a rather vague idea what serotonin is...some brain chemical that is connected to a person’s feeling of well-being. They might also know that serotonin levels are modified by the foods we eat and the drugs we take. Beyond that, most people don’t know a lot.

The Serotonin Syndrome: From Molecular Mechanisms to Clinical Practice

The serotonin syndrome is a medication-induced condition resulting from serotonergic hyperactivity, usually involving antidepressant medications. As the number of patients experiencing medically-treated major depressive disorder increases, so does the population at risk for experiencing serotonin syndrome. Excessive synaptic stimulation of 5-HT2A receptors results in autonomic and neuromuscular aberrations with potentially life-threatening consequences.

The serotonin syndrome—the need for physician’s awareness

SS occurs with increasing frequency, and most cases resolve with prompt recognition and supportive care. There is no role of antipyretic agents since the increase in temperature is due to muscular activity. Physical restraints are ill advised since they can worsen hyperthermia and lactic acidosis. Certain pharmacologic agents, such as cyproheptadine and chlorpromazine, may have a limited role in management, but their efficacy has not been proven in clinical trials.

Think Like a Doctor: A Confused and Terrified Patient Solved

Serotonin syndrome is an unusual but potentially life-threatening condition caused by excess levels of the body chemical serotonin in the central nervous system. It is usually seen in those who accidentally take too many medications that increase serotonin levels in the brain. The well-described triad of symptoms seen in serotonin syndrome consists of changes in mental status, like confusion or agitation; changes in heart rate, blood pressure or body temperature; and changes in muscle function, usually tremors or exaggerated reflexes.

What Serotonin Has To Do With Depression And How To Make More

Your overall mood is greatly influenced by this neurochemical and like Goldilocks, your serotonin need to be just right. Studies have connected low levels with physical and mental problems, and too much can be dangerous, leading to a condition known as serotonin syndrome.

Resources

EMCrit Project

Serotonin syndrome is strongly suggested by the following constellation: (1) Bilateral ankle clonus and hyperreflexia, (2) Lack of another obvious explanation of clonus (no known chronic neurologic abnormality).

Patient

The syndrome is not widely recognised amongst clinicians. A failure to appreciate the syndrome means that mild cases may be overlooked; continuing or increasing the offending drug can cause progression to severe illness. It is underdiagnosed due to the heterogeneity of its presentation...

UpToDate

Serotonin syndrome is often misdiagnosed as NMS, but the two can readily be distinguished on the basis of history, examination findings, and clinical course. NMS develops over days to weeks [10], whereas serotonin syndrome develops over 24 hours.