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Serotonin syndrome following cyclobenzaprine overdose: case report A 27-year-old woman developed serotonin syndrome following an intentional overdose of cyclobenzaprine while receiving concomitant escitalopram [time to reaction onset not clearly stated]. The woman was receiving escitalopram [Lexapro] 10mg daily for mild depression, as well as hydrocodone/paracetamol [acetaminophen] and cyclobenzaprine [Flexeril] 10mg [frequency of administration not stated] as required for lower back pain; she denied using hydrocodone/paracetamol recently. She was feeling "down" and somnolent when found by her parents who took her to the emergency department. She reported that the previous evening she had taken "5 or 6" cyclobenzaprine tablets with two rum beverages because her boyfriend had not called. She was initially responsive, but quickly became stuporous, exhibiting localisation to painful stimuli, nonsensical speech and eye opening to pain. Investigations revealed the following levels: oxygen saturation 94%, respiratory rate 24 breaths/min, body temperature 38.7oC, BP 159/76 mmHg and a pulse rate of 140 beats/min. Physical examination showed diaphoresis, skin flushing, hyper-reflexia, horizontal nystagmus and body-wide rigidity and tremors, especially in the lower extremities. Sinus tachycardia was evident from an ECG, and laboratory tests showed positive opiate and tricyclic screens, a serum alcohol level of 44 mg/dL, respiratory acidosis and a creatinine kinase fraction of 3862 U/L. She was presumptively diagnosed with serotonin syndrome. The woman received axillary cooling, lorazepam, IV fluids, cyproheptadine and diazepam. Her pH, creatinine kinase fraction, tachycardia, tremors and temperature improved over the following 12 hours. Although tired, she was orientated as her mental status returned to baseline. She was discharged 2 days after a psychiatric assessment and advised to stop cyclobenzaprine while taking an antidepressant. Author comment: "We posit in this case that the addition of an overdose of Flexeril to the patient’s Lexapro regimen caused her presentation." Day LT, et al. Serotonin syndrome in a patient taking Lexapro and Flexeril: a case report. American Journal of Emergency Medicine 26: 1069.e1-1069e.3, No. 9, Nov 801124579 2008 - USA

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Reactions 15 Nov 2008 No. 1228