Jornal de Metabolismo e Toxicologia de Drogas
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Serotonin Syndrome: Opportunity for Missed Diagnosis

Daryl J. Di Rocco, Timothy Costello and David J. Watts

Background: Serotonin syndrome is a clinical entity recognized with increasing frequency due to the prevalence with which pro-serotonergic drugs are prescribed and combined across the different medical fields. The common clinical presentation of serotonin syndrome involves autonomic instability, neuromuscular abnormalities, and mental status changes. Objectives: This case report seeks to describe a case where current recommendations regarding observation and disposition could have led to a missed diagnosis and disastrous results. Case Report: We present a 32-year-old female with depression, on daily selective serotonin reuptake inhibitor (SSRI) therapy, who presents after suicide attempt involving the pro-serotonergic agents fluoxetine (80mg) and tramadol (1600mg) and ultimately develops severe serotonin syndrome requiring ICU transfer after remaining essentially asymptomatic for 12 hours. Conclusion: Emergency and critical care providers should be familiar with serotonin syndrome and aware that an overdose of multiple serotonergic agents may require prolonged observation or conservative medical admission of asymptomatic patients prior to transfer to a psychiatric care unit where the development of symptoms may go unrecognized or improperly treated.