Hyperpyrexia following psychotropic drug overdose

The serotonin syndrome and its treatment

Serotonin syndrome is caused by drug induced excess of intrasynaptic 5-hydroxytryptamine. The clinical manifestations are mediated by the action of 5-hydroxytryptamine on various subtypes of serotonin receptors. There is no effective drug treatment established. The history of the treatment of serotonin syndrome with 5-hydroxytryptamine blocking drugs is reviewed. A literature search was undertaken using both Medline and a manual search of the older literature. Reports of cases treated with the 5-HT2 blockers cyproheptadine and chlorpromazine were identified and analysed. There is some evidence suggesting the efficacy of chlorpromazine and cyproheptadine in the treatment of serotonin syndrome. The evidence for cyproheptadine is less substantial, perhaps because the dose of cyproheptadine necessary to ensure blockade of brain 5-HT2 receptors is 20-30 mg, which is higher than that used in the cases reported to date (4-16 mg).

Serotonin syndrome. A clinical update

Serotonin syndrome is characterized by varied degrees of cognitive, autonomic, and neuromuscular dysfunction and can only be produced by drug therapy that increases central nervous system serotonin neurotransmission. Information gained from a retrospective review of 127 cases of serotonin syndrome is presented. It is not uncommon for severe cases of serotonin syndrome to be confused with neuroleptic malignant syndrome. Treatment is mainly supportive, but specific pharmacologic therapy with serotonin antagonists may be potentially beneficial.

A rapidly progressing lethal case of neuroleptic malignant syndrome

A fast progressing lethal case of neuroleptic malignant syndrome (NMS) complicated by disseminated intravascular coagulation (DIC) is presented. The fulminant course is infrequent and relates NMS to malignant hyperthermia. Muscular relaxation in combination with fluid load dramatically decreased the temperature, but the catastrophic course of this case was so advanced that the currently recommended treatment of NMS was impossible.

Fatal disseminated intravascular coagulation following a monoamine oxidase inhibitor/tricyclic interaction

In spite of intensive therapy, an otherwise fit 34-year-old man died following the hyperpyrexial reaction to an interaction between tranylcypromine and clomipramine. There was no evidence of drug overdose, but severe disseminated intravascular coagulation developed which proved fatal.

The neuroleptic malignant syndrome. Case report with a review of the literature

Following the administration of fluphenthixol (a depot phenothiazine) for a psychotic illness, a 44-year-old woman developed weakness, rhabdomyolysis and renal failure, together with hyperthermia (42 degrees C) and signs of both autonomic and central nervous system dysfunction. She died following massive intestinal haemorrhage, intra-abdominal sepsis and probable disseminated intravascular coagulation. A diagnosis of neuroleptic malignant syndrome had been made, but treatment with dantrolene sodium was probably instituted too late to prevent the progress of the complications she had developed. This syndrome, which follows the use of phenothiazines or butyrophenones, is rare, potentially fatal and probably underdiagnosed. It has been likened to malignant hyperthermia, but a review of the literature points to many differences. Both dantrolene sodium and dopaminergic drugs (bromocriptine, amantidine and L-dopa) have been shown to be efficacious and their continued use, despite a failure in this case, is advocated until more is known about this syndrome.