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Citalopram Overdose Leading to Cardiac Instability and Late-Onset Severe Serotonin Syndrome FREE TO VIEW

Patrick Smith, DO; Joseph Zeman, MD; Timothy Quast, MD
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Walter Reed National Military Medical Center, North Bethesda, MD

Chest. 2014;146(4_MeetingAbstracts):252A. doi:10.1378/chest.1991575
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SESSION TITLE: Critical Care Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: In intentional overdose, citalopram has been rarely reported to lead to QTC prolongation and Torsade de Pointes. We present an unusual case where intentional Citalopram overdose was associated with dramatic QTC prolongation and arrhythmias in addition to a delayed onset severe serotonin syndrome.

CASE PRESENTATION: A 42 year old woman with a history of Major Depressive Disorder presented with citalopram, temazepam and clonazepam overdose. She was nonresponsive and was admitted to the ICU after intubation. On hospital day one, she had electrolyte lability with a calcium of 6.8 mg/dL, magnesium of 1.7 mg/dL and potassium of 2.4 mmol/L and subsequent Qtc prolongation and multiple arrhythmias. On hospital day 4 she became less responsive, hypertonic, hyperthermic and developed new ocular myoclonus and babinski’s reflex. She received cyproheptadine for late onset serotonin syndrome and had complete resolution of symptoms six hours after administration.

DISCUSSION: Cardiac toxicity is a rare but serious consequence of citalopram overdose. In our patient with an intentional overdose estimated of greater than 2000 mg of citalopram, cardiac instability developed within 8 hours after ingestion, and resolved within the first 24 hours with aggressive correction of her electrolyte abnormalities, suggesting a potential mechanism for Torsades de Pointes associated with citalopram. Serotonin Syndrome is a documented side effect with all selective serotonin reuptake inhibitors seen in intentional overdose. In the case of coingestions, as in our patient, an overdose of a benzodiazepine can mask the signs and symptoms of serotonin syndrome and potentially delay a life saving diagnosis. Similarly, sedative medications used for patients on the ventilator can mask the initial clinical signs of serotonin syndrome. Physical exam clues, such as ocular myoclonus in our patient, can be used to make a diagnosis of serotonin syndrome in these settings.

CONCLUSIONS: We present a rare case of severe citalopram overdose leading to electrical cardiac instability and serotonin syndrome. It is important for clinicians to be aware of the potential of delayed onset serotonin syndrome in the setting of intentional overdose with selective serotonin receptor inhibitors with coingestion of benzodiazepines.

Reference #1: Jimmink A, Caminada K, Hunfeld N, Touw D. Clinical Toxicology of Citalopram After Acute Intoxication With the Sole Drug or in Combination With Other Drugs: Overview of 26 Cases. Ther Drug Monit. 2008; 30: 365-371.

DISCLOSURE: The following authors have nothing to disclose: Patrick Smith, Joseph Zeman, Timothy Quast

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