Linezolid-Induced Serotonin Toxicity in a Patient Not Taking Monoamine Oxidase Inhibitors or Serotonin Receptor Antagonists

Sutton, Jacob; Stroup, Jeff; Som, Mousumi

doi:10.1080/08998280.2016.11929423

Cited by 11 publications

(5 citation statements)

References 10 publications

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“…Based on published reports, the incidence of linezolid‐associated serotonin toxicity is between 0.54% and 18.2% and usually due to a combination of linezolid and a selective serotonin reuptake inhibitor (SSRI) . Linezolid‐induced serotonin toxicity may also occur even without any history of intake of SSRI or MAO inhibitor . Consistent in the presentation of these patients is the rapid improvement of clinical features after discontinuation of linezolid.…”

Section: Discussionmentioning

confidence: 99%

Serotonin syndrome masquerading as disease flare in lupus nephritis with end‐stage renal disease

2019

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Introduction Serotonin syndrome is a potentially life‐threatening condition characterized by the triad of mental status changes, autonomic instability, and neuromuscular changes. We report a case of serotonin syndrome masquerading as disease flare in a lupus nephritis patient with end‐stage renal disease receiving linezolid for the treatment of infected pseudoaneurysm. Case report A 36‐year‐old female lupus nephritis patient on maintenance hemodialysis for end‐stage renal disease had been on multiple antibiotics, including anti‐tuberculosis medications, over the past month for infected pseudoaneurysm complicating her arteriovenous fistula. Due to minimal response, she underwent pseudoaneurysmal ligation and given linezolid. Two days later, she developed chest pain, tachycardia, hypertension, tremors, later accompanied by high‐grade fever, diarrhea, insomnia, and body weakness. Although fully awake and oriented, she was markedly agitated, mildly icteric, had hyperreflexia and asthenia with proximal muscle strength graded 3/5 in all extremities. Blood counts revealed anemia and thrombocytopenia; ancillary tests showed aspartate aminotransferase markedly higher than alanine aminotransferase, elevated serum lactate dehydrogenase and creatine kinase, and low C3 levels. Intravenous hydrocortisone was started for a suspected lupus flare. On the background of linezolid, isoniazid, and tramadol administration, serotonin syndrome with rhabdomyolysis was strongly considered. Offending drugs were discontinued, resulting in the dramatic improvement of symptoms and improved strength and well‐being. The steroid was successfully tapered to 5 mg/day and a week later, she remained afebrile without recurrence of symptoms. Conclusion Serotonin syndrome should be considered in patients on multiple serotonergic agents on the background of end‐stage renal disease. Prompt recognition and distinction from lupus activity can significantly impact management decisions.

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Section: Discussionmentioning

confidence: 99%

Serotonin syndrome masquerading as disease flare in lupus nephritis with end‐stage renal disease

2019

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“…Management for presumed SS was undertaken based on published guidelines, 3,5 which included the following: aggressive hydration with boluses of normal In consultation with toxicology, a morphine infusion at 30 mcg/kg/hr was initiated to help prevent withdrawal from the longstanding usage of opioids. Morphine was considered to be the safest opioid to administer in terms of serotonergic effects as opposed to fentanyl or methadone.…”

Section: Case Descriptionmentioning

confidence: 99%

“…Linezolid, an oxazolidinone antibiotic used for the treatment of resistant Gram-positive cocci infections, is a non-selective monoamine oxidase inhibitor (MAOI). 3 Common side effects include nausea, vomiting, dizziness, rash, and thrombocytopenia with the rare side effect of SS. 4 This report describes the drug-drug interaction of non-traditional serotonergic agents; an opioid agonist, methadone, and linezolid that caused SS in a pediatric patient in an inpatient setting.…”

Section: Introductionmentioning

confidence: 99%

Serotonin Syndrome in an Infant Associated With Linezolid and Opioid Use

Essakow

Jin

Marupudi

et al. 2022

The Journal of Pediatric Pharmacology and Therapeutics

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Most reported cases of serotonin syndrome involve either a selective serotonin reuptake inhibitor (SSRI) or monoamine oxidase inhibitors (MAOI) and at least 1 other serotonergic medication or exposure to a single serotonin-augmenting drug. This case report describes serotonin syndrome occurring in association with the concomitant use of the antibiotic linezolid and opioids, specifically methadone, in a pediatric intensive care unit patient. The patient developed hyperpyrexia, muscle rigidity, clonus, and multiorgan dysfunction within 48 hours of receiving linezolid while concurrently on methadone. This drug-drug interaction is a rare cause of serotonin syndrome that has only been described 1 other time in the adult literature. This report raises awareness of this rare but serious and potentially lethal complication of serotonin syndrome associated with concomitant linezolid and opioid use. Timely consideration of the diagnosis in the setting of hyperpyrexia can facilitate prompt initiation of targeted therapies to prevent sequela.

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“…2,3 Linezolid has non-selective MAO-A and MAO-B inhibitory effects and can lead to excess amounts of serotonin, especially when combined with other adrenergic and serotonergic agents. [1][2][3][4] Serotonin is converted to 5-hydroxytryptophan (5-HT), which is then transported and degraded by MAO. Serotonin toxicity (ST), which can lead to serotonin syndrome (SS) results from drug-induced excess of serotonin in the central nervous system.…”

Section: Introductionmentioning

confidence: 99%

“…5 Symptoms such as autonomic signs (diaphoresis, tachycardia, hypertonia), neuromuscular changes (hyperreflexia, clonus), and altered mental status can be used to characterize SS. 2,4,6 A systematic review of 46 studies described 56 patients with suspected SS. Fever, seizures, and elevated CK suggested severe SS with poor prognosis without intervention.…”

Section: Introductionmentioning

confidence: 99%

A Case Series on Serotonin Syndrome from Concomitant use of linezolid With Methadone, Buprenorphine, and/or Dextroamphetamine

Huang

Edrees

Lee

2023

Journal of Pharmacy Practice

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Background and Objectives The risk of serotonin syndrome (SS), especially when linezolid is used concomitantly with methadone, buprenorphine, and/or dextroamphetamine, remains widely unstudied and may limit the options for antimicrobial therapy in these patient populations. Methods We reviewed all adult encounters on linezolid with concomitant methadone, buprenorphine, and/or dextroamphetamine from April 2016 to June 2022. The primary outcomes included characterizing prescribing preferences and prevalence of confirmed and possible serotonin syndrome using ICD-10 diagnosis codes, cyproheptadine administration, and electronic medical record chart review using the Hunter Serotonin Toxicity Criteria. Results Overall, 194 encounters were evaluated. 16.5%, 17.8%, and 7.1% were on high dose methadone, buprenorphine, and dextroamphetamine, respectively. Mean duration of overlap with linezolid was 4.6, 3.3, and 7 days respectively. One confirmed and two possible cases of serotonin syndrome were identified. Conclusion Linezolid may be considered in patients who are concomitantly on methadone, buprenorphine, and/or dextroamphetamine. In our analysis of 194 encounters, one definitive case and two possible cases of SS were identified. Additional real-world studies are necessary to identify if exposure and/or duration may be correlated with an increased risk of serotonin syndrome.

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Linezolid-Induced Serotonin Toxicity in a Patient Not Taking Monoamine Oxidase Inhibitors or Serotonin Receptor Antagonists

Cited by 11 publications

References 10 publications

Serotonin syndrome masquerading as disease flare in lupus nephritis with end‐stage renal disease

Serotonin syndrome masquerading as disease flare in lupus nephritis with end‐stage renal disease

Serotonin Syndrome in an Infant Associated With Linezolid and Opioid Use

A Case Series on Serotonin Syndrome from Concomitant use of linezolid With Methadone, Buprenorphine, and/or Dextroamphetamine

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