Citalopram overdose
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Serotonin syndrome and QT prolongation secondary to citalopram toxicity following ingestion of citalopram at an overdose in an attempt to commit suicide: case report A 25-year-old woman developed serotonin syndrome and QT prolongation secondary to citalopram toxicity following ingestion of citalopram at an overdose in an attempt to commit suicide. The woman, who had a history of depression, presented to the emergency department 7h following ingestion of 760mg of citalopram in an attempt to commit suicide. Upon presentation, she was found to be anxious and tremulous with HR of 162 beats/min, BP of 107/69mm Hg, RR of 18 breaths/min and body temperature of 36.7°C. She developed tonic-clonic seizure activity. She was intubated for airway protection using midazolam and fentanyl for continuous sedation. The woman received magnesium sulfate for the QT prolongation. Initial laboratory investigations revealed leucocytosis, elevated anion gap and low bicarbonate. Medical toxicology was consulted and she was admitted to the ICU. On evaluation in the ICU, she was found to be hyperthermic with severe rigidity and difficulty eliciting clonus due to hypertonia. A recommendation was made to discontinue fentanyl, titrate midazolam infusion to relaxed tone and administer cyproheptadine per nasogastric tube three times daily. Additionally, escalating doses of phenobarbital were recommended as needed for additional symptom control. There was persistent lower extremity rigidity with hyperreflexia, tremors and clonus, despite aggressive sedation and external cooling. Her creatine kinase was found to be increased 42h post citalopram ingestion. Her body temperature was found to be increased on day 2 post citalopram ingestion. Her body temperature improved and remained below 38°C on day 3. Pentobarbital was started in the evening of day 3 due to persistent neuromuscular findings. The following morning, her neuromuscular excitation considerably improved. Pentobarbital was gradually tapered and eventually discontinued on day 6. Despite normal neuromuscular exam noted on day 5, fever returned and unspecified antibiotics were administered for suspected aspiration pneumonia. On day 9, she was extubated. Comprehensive urine drug screening detected only citalopram, with concentrations of 2900 ng/mL, 730 ng/mL and 340 ng/mL at 7h, 53h and 65h after ingestion, respectively. Her renal and hepatic function remained normal throughout hospitalisation. She was eventually diagnosed with serotonin syndrome. Additionally, pharmacogenetic testing showed that she was an intermediate CYP2C19 metabolizer, which might have decreased citalopram inactivation leading to an increased concentration and toxicity [not all outcomes stated]. Author comment: "Our patient had severe toxicity after single agent ingestion." "We report a case of severe serotonin syndrome following citalopram overdose in a patient with intermediate CYP2C19 metabolism." Schult RF, et al. Citalopram overdose and severe serotonin syndrome in an intermediate metabolizing patient. American
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