Maria and Ivo: two stories, the same diagnostic suspicion

For privacy reasons case reports are written in way to make the patient unidentifiable. The two cases have been reported to the Italian National Pharmacovigilance Network.

Case 1:
Maria, 77 years old, suffers from high blood pressure, hypothyroidism and cognitive decline. Only few months ago she was hospitalised for a fall resulting in a head injury, probably due to an inappropriate use of zolpidem. Following the incident, the drug was discontinued along with a gradual cessation of sertraline and the start of treatment with promazine. The hospitalisation seemed to be only a distant memory until one warm September night Maria was accompanied back to the emergency room by her family. She was visibly confused, with a high fever and chills, a blank expression and aphasia. Yet until before she went to bed she seemed well, as reported by her nephew to the emergency room doctor who, considering the situation, decided to subject her to initial medical examinations. Maria’s vital parameters, with the exception of her body temperature, appeared normal, as well as the blood gas analysis. Blood and urine tests also do not reveal any significant abnormalities, except for a positive leucocyte esterase test and the presence of nitrites in the latter case. On the other hand, the chest X-ray revealed a slight thickening in the basal area.
The emergency room doctors, alarmed by Maria’s condition, promptly requested a CT scan of her skull, which resulted negative.
Since no improvement in the clinical condition was observed, Maria underwent further investigations, including a neurological evaluation, on suspicion of a systemic infection, which was not confirmed. In light of the uncertain situation, an infectivological opinion is also requested, discouraging the introduction of antibiotic therapy in the absence of a clear indication.
As the hours pass, the family’s apprehension about Maria increases and the nephew, on the instructions of the medical staff, tries to clarify the medication taken by the woman. When he returned home, searching through Maria’s medicine drawer, he found, next to several packages of sertraline, a crumpled sheet of paper that seemed to indicate the woman’s therapy: lansoprazole, levothyroxine, bisoprolol, ramipril, acetylsalicylic acid 100 mg, sertraline 25 mg 1 cp h22 (apparently never discontinued), zolpidem 10 mg as needed for insomnia.
Tests showed no signs of inflammation and without any specific therapy, Maria began to improve gradually until on the third day of hospitalisation, she regained consciousness, the ability to communicate and mobility.
The presence of a considerable stockpile of sertraline at home and the possibility that the patient had self-administered the drug, despite her mental state, leads the doctors to believe that there is a high probability that Maria is suffering from an atypical serotonergic syndrome. Consequently, sertraline therapy is stopped permanently and treatment with quetiapine in increasing dosages is started before discharge.

Case 2:
Ivo, 78 years old, is urgently transported to the emergency room in critical conditions: he presents general limb rigidity, mutacism, tachypnoea, sphincter release, vomiting and hyperpyrexia up to 39°C. The pathological history reveals that Ivo suffers from diabetes mellitus in diet therapy, cognitive impairment and a recently worsened reactive depressive syndrome, for which he has been taking sertraline in addition to chlorpromazine since some days before going to bed.
In the emergency room, the first investigations do not seem to reveal any significant abnormality: the haematochemical tests appear normal, and the urine test is not suggestive of the presence of a urinary tract infection. The brain scan, performed to investigate possible neurological involvement, shows signs of mild chronic vascular damage, with no acute emergency. The electroencephalogram and spinal tap also exclude the presence of a central nervous system infection. In the light of this situation, difficult to interpret, the decision was taken to admit Ivo for a more intensive monitoring and symptom management.
However, an in-depth examination of the pharmacological history reveals an important detail: it turns out that Ivo, on the recommendation of a friend, in addition to his usual therapy, also takes Hypericum (St. John’s wort) as a supplement for depression. This leads to the hypothesis of a serotonergic syndrome, a serious but rare complication caused by the interaction between the supplement and sertraline, recently added to the therapy. After the difficult diagnosis, Ivo was given the antidote along with supportive care to control his symptoms.
After discontinuation of the implicated drugs and adoption of the supportive measures, Ivo shows a significant improvement in symptoms that continues until full recovery of residual motor and cognitive functions.