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Zorluk: OrtaPharmacologic Interventions

A 45-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and shivering that began earlier today. She has a history of major depressive disorder and was recently diagnosed with a soft tissue infection. Her daily home medications include citalopram. Three days ago, she was started on oral linezolid. Her temperature is 39.1°C (102.4°F), blood pressure is 165/95 mmHg, pulse is 122/min, and respiratory rate is 22/min. Physical examination reveals profuse diaphoresis, dilated pupils, and hyperreflexia with inducible myoclonus in the bilateral lower extremities. Intravenous fluids and lorazepam are administered, but her symptoms persist. Which of the following pharmacologic interventions is the most appropriate next step in management?

  1. CyproheptadineCevap
  2. B
    Dantrolene
  3. C
    Bromocriptine
  4. D
    Physostigmine
  5. E
    Haloperidol

Cevap

Cyproheptadine
The correct answer is cyproheptadine. This patient is exhibiting classic signs of serotonin syndrome, precipitated by the combination of citalopram (a selective serotonin reuptake inhibitor) and linezolid (an antibiotic that also functions as a weak monoamine oxidase inhibitor). The clinical triad consists of altered mental status, autonomic hyperactivity (tachycardia, hyperthermia, diaphoresis), and neuromuscular abnormalities (hyperreflexia, clonus). Initial management includes discontinuing the offending drugs, providing supportive care with intravenous fluids, and administering benzodiazepines to control agitation and muscle hypertonicity. Because this patient's severe symptoms persist despite lorazepam, the administration of cyproheptadine, a 5-HT2 receptor antagonist, is the most appropriate next step in management.

Adım Adım Çözüm

1
Identify the clinical toxidrome based on history and physical exam findings.
The patient has hyperthermia, autonomic instability, altered mental status, diaphoresis, and neuromuscular hyperactivity (hyperreflexia, clonus).
These are the classic signs of serotonin syndrome.
2
Review the medication history for causative agents.
The patient is taking citalopram (a selective serotonin reuptake inhibitor) and was recently prescribed linezolid (an antibiotic with weak monoamine oxidase inhibitor properties).
The combination of these serotonergic agents precipitated the syndrome.
3
Determine the appropriate pharmacologic management for severe, refractory cases.
Cyproheptadine should be administered.
Initial management includes discontinuing the offending agents, supportive care, and benzodiazepines. Because her symptoms persist despite lorazepam, a 5-HT2 receptor antagonist (cyproheptadine) is indicated.

Anahtar Kavram

Management of severe serotonin syndrome with cyproheptadine when supportive care and benzodiazepines are insufficient.
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Pharmacologic Interventions

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