PC2140: Agitated Adult in a Pediatric Hospital

Introduction: Serotonin syndrome is uncommon and if untreated can have significant mortality. Reviewing patient history, medications, and social history is critical for diagnosis.

Case Description: A 31-year-old female with a past medical history of depression, anxiety, bicuspid aorta, coarctation of the aorta, and hypertension was admitted to a pediatric hospital for routine cardiac catheterization and balloon dilation of aortic coarctation by the adult congenital heart disease team. Postoperatively, the patient developed significant agitation. She received opiates and benzodiazepines for agitation attributed to pain in anesthesia recovery. Her symptoms worsened; thus, she received haloperidol, intravenous diphenhydramine, and additional opiates. Four hours later, Internal Medicine-Pediatrics (Med-Peds) service was consulted “stat” to help manage and evaluate possible drug-seeking behavior due to a history of non-prescription substance use.

On exam, her vital signs were notable for a blood pressure of 169/110 mmHg, heart rate of 150 beats/min, and respiratory rate of 38 breaths/min with significant anxiety and agitation. She was diaphoretic with diffuse abdominal tenderness, ankle clonus, and a fine resting tremor of all extremities. The patient had a sense of impending doom and stated several times, “Something is wrong with me; please help.”
Upon reviewing the home medications and operating room medication reports, the Med-Peds consult team determined the patient met the Hunter toxicity criteria (1) for serotonin syndrome. Due to her symptoms, the patient required a cyproheptadine load and several doses of beta blockers before needing pediatric intensive care unit admission for a beta-blocker drip. The patient met discharge criteria four days later, after the resolution of her serotonin syndrome and medication adjustment.

Discussion: Serotonin syndrome is a difficult diagnosis due to low incidence and nonspecific symptoms. However, as serotonergic medication uses increase, we can expect more frequent toxicities. In 2019 U.S. poison control reported 4172 moderate to severe cases involving serotonergic agents.² In fact SSRI’s and SNRI’s are now both in the top 25 “minor generic categories” with largest fatalities.² Several case reports have highlighted the use of peri-operative medications inducing the syndrome in adults.³ The case was more complicated due to it occurring in a pediatric facility where serotonin syndrome is much less likely to occur due to fewer psychiatric medications. Practitioners must be vigilant to review medications and histories, and keep a broad differential diagnosis.

Conclusion: Serotonin syndrome is uncommon and if untreated can have significant mortality. Reviewing patient history, medications, and social history is critical for diagnosis. The case was more complicated due to it occurring in a pediatric facility where serotonin syndrome is much less likely to occur. The case highlights the importance of internal medicine trained physicians available to manage adults at pediatric facilities and a thorough medicine administration record reconciliation with every hospital admission.