Challenges in the Management of Severe Serotonin Syndrome: A Case Report

Serotonin syndrome (SS) is a potentially life-threatening condition that can result from excessive serotonergic activity, often due to SSRIs, formally known as selective serotonin reuptake inhibitors. The syndrome and its effects are often secondary to drug-drug interactions or dose-related. This case highlights a 47-year-old female who presents with a history of major depressive disorder, generalized anxiety disorder, and severe alcohol use disorder. She was brought to the Emergency Department after attempting suicide by ingesting an inordinate amount of bupropion (Wellbutrin). Although bupropion is not a direct serotonergic reuptake inhibitor, its inhibition of the CYP2D6 pathway has the potential to elevate the levels of alternative serotonergic agents, potentially leading to SS. The patient's symptoms were inclusive of autonomic instability and clonus, which are consistent with this syndrome, and which necessitated the discontinuation of all serotonergic medications, in addition to the initiation of supportive care. Management included benzodiazepines, guanfacine, and gabapentin to mitigate the glutamatergic activity SS can induce. This case emphasizes the need to closely monitor those prescribed this class of medications, while concomitantly incorporating interdisciplinary collaborative management for those afflicted with SS.