BackgroundSerotonin syndrome is a potentially life-threatening condition associated with increased serotonergic activity in the central nervous system. Serotonin syndrome is underreported complication of pharmacotherapy. The Hunter Criteria for serotonin syndrome (SS) are fulfilled if the patient has taken a serotonergic agent and has one of the following symptoms: 1) spontaneous clonus, 2) inducible clonus and agitation or diaphoresis, 3) ocular clonus and agitation or diaphoresis, 4) tremor and hyperreflexia, 5) hypertonia, or 6) temperature above 38 C and ocular clonus or inducible clonus.MethodPatient A was a 16-year-old Caucasian male with history of major depressive disorder, social anxiety and OCD who presented to the emergency room with multiple complaints: twitching of bilateral cheeks, intermittent tremor of his hands and feet, mental fogginess/confusion, stuttering when attempting to speak, agitation, profuse sweating and headache. 3 weeks prior, his sertraline dose was increased from 25mg daily to 50 mg daily. His physical exam was remarkable for elevated blood pressure and heart rate as well as hyperreflexia noted on patellar reflex testing. No significant abnormalities were noted on routine labs. He was told his symptoms were likely due to medication side effects. The patient was discharged with instructions to decrease his sertraline dose from 50 mg to 25 mg daily and follow up with his outpatient psychiatrist. 2 days later the patient was seen at the outpatient child psychiatry clinic and he was advised to taper off sertraline completely by taking 12.5mg daily for 3 days before cessation. After stopping the medication, the patient’s symptoms resolved.Patient B was a 16-year-old female with generalized anxiety disorder and major depressive disorder who presented to the general pediatric clinic with progressively worsening hand tremors and body shaking since her Zoloft dose was increased from 25mg to 50mg daily. She also felt it was more difficult to hold objects. At the physical exam she had an elevated heart rate to 93 and elevated blood pressure to 182/75. Her deep tendon reflexes were 4+ bilaterally. Upon consultation with child psychiatry, the patient was recommended to taper off sertraline. After the discontinuation of sertraline, her symptoms resolved.ResultThese 2 patients developed mild to moderate symptoms of serotonin syndrome with low doses of sertraline. Symptoms resolved after the discontinuation of the SSRI.DiscussionIn the pediatric patient population, serotonin syndrome can develop even with lower doses of an SSRI. To avoid a missed diagnosis, clinicians should familiarize themselves with the Hunter Criteria for serotonin syndrome. It is also vital to educate parents and caregivers about the toxicities of SSRIs, including serotonin syndrome, so they may monitor treatment and take appropriate action if needed.

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小剂量舍曲林会导致儿科患者出现血清素综合征吗？2 病例报告

背景血清素综合征是一种可能危及生命的疾病，与中枢神经系统中血清素活性的增加有关。血清素综合征是药物治疗的被低估的并发症。如果患者服用了 5-羟色胺能药物并具有以下症状之一，则满足 5-羟色胺综合征 (SS) 的亨特标准：1) 自发性阵挛，2) 诱导性阵挛和激动或出汗，3) 眼阵挛和激动或出汗， 4) 震颤和反射亢进，5) 肌张力亢进，或 6) 体温高于 38 摄氏度和眼阵挛或诱发性阵挛。急诊室有多个主诉：双侧脸颊抽搐，手脚间歇性震颤，精神模糊/混乱，试图说话时口吃，激动，大量出汗和头痛。3 周前，他的舍曲林剂量从每天 25 毫克增加到每天 50 毫克。他的体格检查显示血压和心率升高，以及髌骨反射测试中发现的反射亢进。常规实验室未发现明显异常。他被告知他的症状可能是由于药物的副作用。患者出院时得到指示，将舍曲林剂量从每天 50 mg 减少到 25 mg，并与门诊精神科医生进行随访。2 天后，该患者在门诊儿童精神病诊所就诊，建议他完全减量舍曲林，每天服用 12.5 毫克，持续 3 天，然后停药。停药后，患者症状缓解。患者 B 是一名患有广泛性焦虑症和重度抑郁症的 16 岁女性，由于她的唑洛特剂量从每天 25 毫克增加到 50 毫克，她到普通儿科诊所就诊，手颤抖和身体颤抖逐渐恶化。她还觉得拿东西更难。在体检时，她的心率升高到 93，血压升高到 182/75。她的双侧深腱反射为 4+。在咨询儿童精神病学后，建议患者逐渐减少舍曲林的用量。停用舍曲林后，她的症状得到缓解。结果这2名患者在服用低剂量舍曲林后出现了轻至中度的5-羟色胺综合征症状。停用 SSRI 后症状得到缓解。讨论在儿科患者群体中，即使使用较低剂量的 SSRI，5-羟色胺综合征也可能发生。为避免漏诊，临床医生应熟悉血清素综合征的亨特标准。教育父母和看护者了解 SSRI 的毒性（包括血清素综合征）也很重要，这样他们就可以监测治疗并在需要时采取适当的行动。