Pediatric Selective Serotonin Reuptake Inhibitor Toxicity Differential Diagnoses

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

Diagnostic Considerations

Serotonin syndrome produces a clinical picture that is very similar to neuroleptic malignant syndrome (NMS). Both syndromes are associated with autonomic dysfunction, alteration of mental status, rigidity, and hyperthermia. Clinical differentiation between these syndromes is very important because management may differ. For example, chlorpromazine may be of some benefit in serotonin syndrome, whereas it may cause further deterioration in NMS. Distinctions between the syndromes include the following:

  • NMS develops in association with neuroleptics, whereas serotonin syndrome develops in association with serotonergic agents
  • NMS has a slow onset (days to weeks) and a slow progression of 24-72 hours, whereas serotonin syndrome has a more rapid onset and progression
  • NMS is associated with bradykinesia and lead pipe rigidity, whereas serotonin syndrome is associated with hyperkinesia and less rigidity
  • NMS is an idiosyncratic reaction to therapeutic doses, whereas serotonin syndrome is a manifestation of toxicity, frequently generated from the combination of 2 drugs with serotonergic activity

A study concluded that although the characteristics of serotonin syndrome are well defined, some physicians may not be aware of the phenomenon. The retrospective review reported that 5 of 7 patients with serotonin syndrome were initially diagnosed with exacerbation of their psychiatric disorder, 2 patients were diagnosed with gastroenteritis, and 1 patient was diagnosed with a severe drug overdose.[8]

Differential Diagnoses

Proceed to Workup
 
 
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].

 
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