J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 7, Number 12, December 2016, pages 554-557

Serotonin Syndrome Induced by Combined Use of Tramadol and Escitalopram: A Case Report

**Table 1.** Examples of Medicines With Potential to Cause Serotonin Syndrome [3, 6-8]
Therapeutic group	Examples of medicines
SSRI antidepressants	Citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
SNRI antidepressants	Venlafaxine, duloxetine
MAOI antidepressants	Tranylcypromine, phenelzine, moclobemide (reversible MAO-A inhibitor), isocarboxazid
Tricyclic antidepressants	Clomipramine, imipramine
Miscellaneous	Lithium, trazodone, L-tryptophan
Opioids	Pethidine, tramadol, methadone, fentanyl, dextromethorphan, dextropropoxyphene, pentazocine, oxycodone
Parkinson’s disease treatment	Selegiline (selective MAO-B inhibitor)
Antibacterials	Linezolid (reversible MAOI activity)
Anti-cancer drugs	Procarbazine
Anticonvulsants	Carbamazepine, valproate
Antiemetics	Promethazine, metoclopramide, ondansetron
Antihistamines	Chlorphenamine
Antimigraine drugs	Triptans, e.g. frovatriptan, almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan. Dihydroergotamine
Anti-smoking aids	Bupropion
Anxiolytics	Buspirone
Diagnostic dye	Methylthioninium chloride (methylene blue) (15) has reversible MAOI activity (16)
Herbal products	St John’s wort
Street drugs	Cocaine, LSD

Table 1. Examples of Medicines With Potential to Cause Serotonin Syndrome [3, 6-8]

Therapeutic group

Examples of medicines

SSRI antidepressants

Citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

SNRI antidepressants

Venlafaxine, duloxetine

MAOI antidepressants

Tranylcypromine, phenelzine, moclobemide (reversible MAO-A inhibitor), isocarboxazid

Tricyclic antidepressants

Clomipramine, imipramine

Miscellaneous

Lithium, trazodone, L-tryptophan

Opioids

Pethidine, tramadol, methadone, fentanyl, dextromethorphan, dextropropoxyphene, pentazocine, oxycodone

Parkinson’s disease treatment

Selegiline (selective MAO-B inhibitor)

Antibacterials

Linezolid (reversible MAOI activity)

Anti-cancer drugs

Procarbazine

Anticonvulsants

Carbamazepine, valproate

Antiemetics

Promethazine, metoclopramide, ondansetron

Antihistamines

Chlorphenamine

Antimigraine drugs

Triptans, e.g. frovatriptan, almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan. Dihydroergotamine

Anti-smoking aids

Bupropion

Anxiolytics

Buspirone

Diagnostic dye

Methylthioninium chloride (methylene blue) (15) has reversible MAOI activity (16)

Herbal products

St John’s wort

Street drugs

Cocaine, LSD

**Table 2.** Differential Diagnosis of Serotonin Syndrome [11-14]
Clinical condition	History	Vital signs	Clinical features
Anticholinergic syndrome	Use of tricyclic antidepressants or other anticholinergic drugs	Tachycardia, tachypnea, hyperthermia (usually 102.2 °F (39 °C) or below)	Dry mouth, blurred vision, mydriasis, flushed skin, agitation/delirium, decreased bowel sounds
Malignant hyperthermia	Administration of halogenated inhalational anesthetics or depolarizing muscle relaxants	Hypertension, tachycardia, tachypnea, hyperthermia (up to 114.8 °F (46 °C))	Diaphoresis, mottled skin, agitation, decreased bowel sounds, muscular rigidity, hyporeflexia
Neuroleptic malignant syndrome [11-14]	Ingestion of antipsychotic medications	Hypertension, tachycardia, tachypnea, hyperthermia (above 105.8 °F (41 °C))	Sialorrhea, diaphoresis, pallor, stupor, mutism, coma, normal or decreased bowel sounds, lead-pipe rigidity, bradyreflexia

Table 2. Differential Diagnosis of Serotonin Syndrome [11-14]

Clinical condition

History

Vital signs

Clinical features

Anticholinergic syndrome

Use of tricyclic antidepressants or other anticholinergic drugs

Tachycardia, tachypnea, hyperthermia (usually 102.2 °F (39 °C) or below)

Dry mouth, blurred vision, mydriasis, flushed skin, agitation/delirium, decreased bowel sounds

Malignant hyperthermia

Administration of halogenated inhalational anesthetics or depolarizing muscle relaxants

Hypertension, tachycardia, tachypnea, hyperthermia (up to 114.8 °F (46 °C))

Diaphoresis, mottled skin, agitation, decreased bowel sounds, muscular rigidity, hyporeflexia

Neuroleptic malignant syndrome [11-14]

Ingestion of antipsychotic medications

Hypertension, tachycardia, tachypnea, hyperthermia (above 105.8 °F (41 °C))

Sialorrhea, diaphoresis, pallor, stupor, mutism, coma, normal or decreased bowel sounds, lead-pipe rigidity, bradyreflexia