Serotonin syndrome in patients with peripheral neuropathy: a diagnostic challenge

Prakash, Sanjay; Gosai, Falgun; Brahmbhatt, Jit; Shah, Chintan

doi:10.1016/j.genhosppsych.2014.03.012

Cited by 9 publications

(5 citation statements)

References 8 publications

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“…Thirdly, HC may not perform well in patients with other underlying neurological pathologies. Hyperreflexia or clonus, two essential HC symptoms, may not occur in patients with peripheral neuropathy where nerve damage “masks upper motor neuron signs” [ 17 ]. Equally, reflexes or clonus may not be elicitable in patients with severe SS who have developed substantial muscle rigidity [ 1 ].…”

Section: Discussionmentioning

confidence: 99%

Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases

et al. 2016

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BackgroundSerotonin syndrome is a toxic state, caused by serotonin (5HT) excess in the central nervous system. Serotonin syndrome’s main feature is neuro-muscular hyperexcitability, which in many cases is mild but in some cases can become life-threatening. The diagnosis of serotonin syndrome remains challenging since it can only be made on clinical grounds. Three diagnostic criteria systems, Sternbach, Radomski and Hunter classifications, are available. Here we test the validity of four assumptions that have become widely accepted: (1) The Hunter classification performs clinically better than the Sternbach and Radomski criteria; (2) in contrast to neuroleptic malignant syndrome, the onset of serotonin syndrome is usually rapid; (3) hyperthermia is a hallmark of severe serotonin syndrome; and (4) serotonin syndrome can readily be distinguished from neuroleptic malignant syndrome on clinical grounds and on the basis of medication history.MethodsSystematic review and meta-analysis of all cases of serotonin syndrome and toxicity published between 2004 and 2014, using PubMed and Web of Science.ResultsTwo of the four assumptions (1 and 2) are based on only one published study each and have not been independently validated. There is little agreement between current criteria systems for the diagnosis of serotonin syndrome. Although frequently thought to be the gold standard for the diagnosis of the serotonin syndrome, the Hunter criteria did not perform better than the Sternbach and Radomski criteria. Not all cases seem to be of rapid onset and only relatively few cases may present with hyperthermia. The 0 differential diagnosis between serotonin syndrome and neuroleptic malignant syndrome is not always clear-cut.ConclusionsOur findings challenge four commonly made assumptions about serotonin syndrome. We propose our meta-analysis of cases (MAC) method as a new way to systematically pool and interpret anecdotal but important clinical information concerning uncommon or emergent phenomena that cannot be captured in any other way but through case reports.Electronic supplementary materialThe online version of this article (doi:10.1186/s12883-016-0616-1) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases

et al. 2016

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“…20 Other criticisms of the HSTC include their validity/generalisability to nonoverdose cases, given the criteria were derived solely from single SSRI overdoses; that a percentage of the cases in the derivation data set was also present in the test data set in the original study, which could potentially lead to an overestimation of the validity of the criteria 20 ; and finally that they may not perform well in patients with concomitant neurological disease. The cardinal signs of hyperreflexia and clonus may be masked, both in patients with peripheral neuropathy, 102 as well as those with severe SS who have substantial muscle rigidity. 7 In addition to truncal rigidity, in severe, life-threatening cases of SS rapidly rising temperatures above 38°C and peripheral hypertonicity are usually key features.…”

Section: Diagnosismentioning

confidence: 99%

Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions

Scotton

Hill

Williams

et al. 2019

Int J�Tryptophan�Res

147

161

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Serotonin syndrome (SS) (also referred to as serotonin toxicity) is a potentially life-threatening drug-induced toxidrome associated with increased serotonergic activity in both the peripheral (PNS) and central nervous systems (CNS). It is characterised by a dose-relevant spectrum of clinical findings related to the level of free serotonin (5-hydroxytryptamine [5-HT]), or 5-HT receptor activation (predominantly the 5-HT1Aand 5-HT2Asubtypes), which include neuromuscular abnormalities, autonomic hyperactivity, and mental state changes. Severe SS is only usually precipitated by the simultaneous initiation of 2 or more serotonergic drugs, but the syndrome can also occur after the initiation of a single serotonergic drug in a susceptible individual, the addition of a second or third agent to long-standing doses of a maintenance serotonergic drug, or after an overdose. The combination of a monoamine oxidase inhibitor (MAOI), in particular MAO-A inhibitors that preferentially inhibit the metabolism of 5-HT, with serotonergic drugs is especially dangerous, and may lead to the most severe form of the syndrome, and occasionally death. This review describes our current understanding of the pathophysiology, clinical presentation and management of SS, and summarises some of the drugs and interactions that may precipitate the condition. We also discuss the newer novel psychoactive substances (NPSs), a growing public health concern due to their increased availability and use, and their potential risk to evoke the syndrome. Finally, we discuss whether the inhibition of tryptophan hydroxylase (TPH), in particular the neuronal isoform (TPH2), may provide an opportunity to pharmacologically target central 5-HT synthesis, and so develop new treatments for severe, life-threatening SS.

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“…For instance, patients who have developed substantial rigidity may have become too constrained in their ability to move (Boyer and Shannon, 2005). Clonus and hyperreflexia may not be visible in patients in whom peripheral polyneuropathy masks upper motor neuron signs (Prakash et al, 2014).…”

Section: Taking Diagnostic Criteria To the Testmentioning

confidence: 99%

Serotonin syndrome: a clinical review of current controversies

Werneke¹,

Truedson²,

Wikström³

et al. 2020

Journal of Integrative Neuroscience

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Serotonin syndrome in patients with peripheral neuropathy: a diagnostic challenge

Cited by 9 publications

References 8 publications

Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases

Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases

Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions

Serotonin syndrome: a clinical review of current controversies

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