Pediatric Selective Serotonin Reuptake Inhibitor Toxicity Clinical Presentation

  • Author: Mohamed K Badawy, MD, FAAP; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Nov 8, 2011
 

History

Because the enteric nervous system is richly innervated by serotonin, acute toxicity is frequently manifested by altered gastrointestinal (GI) motility and nausea. The most serious drug-related adverse effect of selective serotonin reuptake inhibitors (SSRIs) is the potential to produce serotonin syndrome.

Serotonin syndrome typically develops within hours or days of the addition of a new serotonergic agent to a medication regimen that already includes serotonin-enhancing drugs. Serotonin syndrome may also develop when a new serotonergic agent is started following the recent discontinuation of another serotonergic drug without allowing an adequate washout period. Isolated overdoses of SSRIs can also cause the syndrome.

Symptoms attributed to serotonin excess may include the following:

  • Restlessness
  • Hallucinations
  • Shivering
  • Diaphoresis
  • Nausea
  • Diarrhea
  • Headache

Following an extensive review of the literature, Sternbach defined the following criteria for the diagnosis of serotonin syndrome[7] :

  • Symptoms must coincide with the initiation or increase in dose of a known serotonergic agent
  • At least 3 of the following symptoms and signs should be present: altered mental status, agitation, tremor, shivering, diarrhea, hyperreflexia, myoclonus, ataxia, or hyperthermia
  • Other etiologies (infections, metabolic disturbances, substance abuse, withdrawal) must be excluded
  • A neuroleptic agent should not have been initiated or increased in dose prior to the onset of the symptoms and signs
Next

Physical Examination

Signs of serotonin excess vary and can be subdivided into the following 3 categories:

  • Mental status changes - Confusion, agitation, and coma
  • Neuromuscular findings - Myoclonus, rigidity, tremors, hyperreflexia (tends to be more prominent in the lower extremities than in the upper ones), clonus, and ataxia
  • Autonomic instability - Hyperthermia (excessive heat generation may develop secondary to prolonged seizure activity, rigidity, or muscular hyperactivity), mydriasis, tachycardia, and blood pressure alterations (hypertension, hypotension)
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Mohamed K Badawy, MD, FAAP  Assistant Professor of Emergency Medicine and Pediatrics, University of Texas Southwestern Medical School; Associate Medical Director, Division of Emergency Medicine, Children's Medical Center Dallas

Mohamed K Badawy, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Frank Anthony Maffei, MD, FAAP  Associate Professor of Pediatrics, Temple University School of Medicine; Medical Director, Pediatric Intensive Care Unit, Janet Weis Children's Hospital at Geisinger Health System

Frank Anthony Maffei, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael E Mullins, MD Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

  1. Schneeweiss S, Patrick AR, Solomon DH, et al. Comparative Safety of Antidepressant Agents for Children and Adolescents Regarding Suicidal Acts. Pediatrics. Apr 12 2010;[Medline].

  2. Hawton K, Bergen H, Simkin S, Cooper J, Waters K, Gunnell D, et al. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry. May 2010;196(5):354-8. [Medline]. [Full Text].

  3. Parks V, Philipp AW, Raje S, Plotka A, Schechter LE, Connell J, et al. Concomitant blockade of 5-HT(1A) receptor and 5-HT transporter: Use of the Hunter Serotonin Toxicity Criteria in a clinical pharmacology study. Eur Neuropsychopharmacol. Jul 4 2011;[Medline].

  4. Gordon JB. SSRIs and St.John's Wort: possible toxicity?. Am Fam Physician. Mar 1 1998;57(5):950,953. [Medline].

  5. Josey ES, Tackett RL. St. John's wort: a new alternative for depression?. Int J Clin Pharmacol Ther. Mar 1999;37(3):111-9. [Medline].

  6. Watson WA, Litovitz TL, Rodgers GC, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2005;23(5):589-666. [Medline].

  7. Sternbach H. The serotonin syndrome. Am J Psychiatry. Jun 1991;148(6):705-13. [Medline].

  8. Attar-Herzberg D, Apel A, Gang N, Dvir D, Mayan H. The serotonin syndrome: initial misdiagnosis. Isr Med Assoc J. Jun 2009;11(6):367-70. [Medline].

  9. [Guideline] Nelson LS, Erdman AR, Booze LL, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). May 2007;45(4):315-32. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.