A 59-year-old woman with schizoaffective disorder is brought to the emergency department by her daughter due to restlessness, sweating, diarrhea, and agitation over the last 24 hours. She was seen 3 days ago in an urgent care clinic for acute lower back pain. Physical examination showed no significant abnormalities and no further testing was ordered. The patient was given renewal prescriptions for haloperidol and benztropine and a new prescription for tramadol, and sent home. She is known to have osteoarthritis, chronic kidney disease, hypertension, and type 2 diabetes mellitus. Her other medications include acetaminophen, glipizide, sitagliptin, sertraline, and hydrochlorothiazide.
Temperature is 38.9 C (102 F), blood pressure is 146/94 mm Hg, pulse is 110/min and regular, and respirations are 16/min. Oxygen saturation on room air is 97%. The patient appears restless and startles easily. She has slow, continuous horizontal eye movements. Her neck is supple. Cardiopulmonary and abdominal examinations are within normal limits. She has a tremor and is hyperreflexic in her arms and legs. She has sustained bilateral patellar and ankle clonus, and Babinski sign is present bilaterally. Muscle tone is increased diffusely.
Which of the following is the most likely diagnosis in this patient?

Question

A 59-year-old woman with schizoaffective disorder is brought to the emergency department by her daughter due to restlessness, sweating, diarrhea, and agitation over the last 24 hours.  She was seen 3 days ago in an urgent care clinic for acute lower back pain.  Physical examination showed no significant abnormalities and no further testing was ordered.  The patient was given renewal prescriptions for haloperidol and benztropine and a new prescription for tramadol, and sent home.  She is known to have osteoarthritis, chronic kidney disease, hypertension, and type 2 diabetes mellitus.  Her other medications include acetaminophen, glipizide, sitagliptin, sertraline, and hydrochlorothiazide.
Temperature is 38.9 C (102 F), blood pressure is 146/94 mm Hg, pulse is 110/min and regular, and respirations are 16/min.  Oxygen saturation on room air is 97%.  The patient appears restless and startles easily.  She has slow, continuous horizontal eye movements.  Her neck is supple.  Cardiopulmonary and abdominal examinations are within normal limits.  She has a tremor and is hyperreflexic in her arms and legs.  She has sustained bilateral patellar and ankle clonus, and Babinski sign is present bilaterally.  Muscle tone is increased diffusely.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_968f_64c0_853d_6943ee9d84b5_MD0002_00 This patient's presentation is consistent with serotonin syndrome, which presents as a triad with varying degrees of: Mental status changesAutonomic hyperactivity, andNeuromuscular abnormalities Mental status changes Autonomic hyperactivity, and Neuromuscular abnormalities Gastrointestinal symptoms and diaphoresis are also common. This syndrome can occur after initiation or dose increase of a serotonergic drug, administration of >2 drugs with serotonergic effects, or intentional overdose of a serotonergic drug. Common precipitating agents include MDMA, tramadol, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, ergot derivatives, linezolid, and tricyclic antidepressants. This patient was given tramadol (a drug that impairs serotonin reuptake) while taking sertraline (a selective serotonin reuptake inhibitor). Diagnosis is made clinically as there is no diagnostic test for this syndrome. Clonus is an important clinical finding. Treatment involves removing the offending drug, benzodiazepines for symptoms (eg, agitation), and supportive care. Critically ill patients require intubation in the intensive care unit. Cyproheptadine is the preferred antidote if supportive measures are unsuccessful. (Choice A) Anticholinergic toxicity can result in elevated temperature and blood pressure, agitation, altered mental status, mydriasis, dry mucous membranes, ileus, and urinary retention. However, anticholinergic toxicity would not cause hyperreflexia, tremors, and clonus. (Choice B) Although restlessness and other extrapyramidal symptoms can occur with haloperidol, the most likely presentation of a patient with haloperidol overdose would be over-sedation, without gastrointestinal symptoms, myoclonus, or other symptoms of serotonin syndrome. (Choice C) Malignant hyperthermia may occur in genetically susceptible patients in the setting of perioperative exposure to volatile anesthetics or succinylcholine. It can lead to muscle rigidity, hyperthermia, and hypercarbia. (Choice D) Neuroleptic malignant syndrome is a life-threatening condition associated with the use of antipsychotics. It is characterized by delirium, very high fevers (often >40 C [104 F]), autonomic instability, and lead-pipe rigidity (rather than hyperreflexia and myoclonus). Educational objective: Serotonin syndrome presents with mental status changes, autonomic hyperactivity, and neuromuscular abnormalities after exposure to serotonergic agents. Clonus is an important clinical finding. Treatment involves removing the offending drug, benzodiazepines for agitation, and supportive care. Cyproheptadine is the preferred antidote if supportive measures are unsuccessful. __________ References: Prevention, recognition, and management of serotonin syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20433130) Tramadol, pharmacology, side effects, and serotonin syndrome: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26218943) Transient serotonin syndrome caused by concurrent use of tramadol and selective serotonin reuptake inhibitor. (http://www.ncbi.nlm.nih.gov/pubmed/25540831)

A 59-Year-Old Woman with Schizoaffective Disorder Is Brought to the Emergency