Serotonin syndrome induced by combined use of sertraline and linezolid

Abstract

Serotonin syndrome is a potentially fatal increase in serotonergic activity in both the central nervous system and peripheral nervous system. The etiology can vary from therapeutic drug use, deliberate overdose, or drug interactions that all lead to an increase in serotonin activity. There are some drugs from different classes that can cause serotonin syndrome either alone at high doses or when combined. We present here a case of an 82-year-old female who presented to the emergency room with high-grade fever, loose stools, burning micturition, and tachycardia. Her current medications included sertraline for depression. She was initially treated on the floor for urosepsis and subsequently managed with antibiotic therapy consisting of cephalosporins. She did not improve so her antibiotics were modified and she was then started on linezolid. Within the first 24 h of taking linezolid, the patient had a rapid clinical deterioration manifesting as restlessness, diaphoresis, tremor, shivering, myoclonus, and high fever (40°C). She also had an acute decompensation of her mental status with disorientation and confusion. As a result, she was transferred to intensive care unit. On clinical examination, she had rigidity and hyperreflexia all the four limbs. Babinski sign was positive. Laboratory test results were unremarkable for sepsis. Sertraline and linezolid were stopped. Within 24 h, the patient's mental status had improved. By the 2 nd day on this treatment regimen, the patient's function returned to baseline, and she was discharged from the hospital. Nevertheless, in our case, the administration of sertraline did not reveal any symptomatic interaction, as the serotonin syndrome was induced only after the addition of linezolid to the treatment regimen. This patient was diagnosed with serotonin syndrome.

Doxycycline-Induced Hand Tremors: Case Report and Review of Antibiotic-Associated Tremors

“…Antibiotic-induced tremors are less frequently observed (Table 1 ) [ 4 - 16 ]. They are not restricted to a specific class of drugs and have occurred after initiating treatment with aminoglycosides, carbapenems, cephalosporins, fluoroquinolones, folate synthesis inhibitor, glycopeptides, macrolides, penicillins, and tetracyclines.…”

“…Serotonin syndrome is another sequalae of medication administration that can lead to tremor. It presents with autonomic instability, behavioral changes, and neurologic symptoms such as tremor, myoclonus, and rigidity [ 16 ]. Multiple antibiotics have been observed to cause serotonin syndrome by interacting with antidepressant medications (Table 2 ) [ 16 - 18 ].…”

“…It presents with autonomic instability, behavioral changes, and neurologic symptoms such as tremor, myoclonus, and rigidity [ 16 ]. Multiple antibiotics have been observed to cause serotonin syndrome by interacting with antidepressant medications (Table 2 ) [ 16 - 18 ]. These antibiotics include fluoroquinolones (ciprofloxacin), folate-synthesis inhibitors (trimethoprim-sulfamethoxazole), and oxazolidinones (linezolid).…”

“…Serotonin syndrome in the setting of a sertraline and linezolid interaction was suspected and both therapies were halted. Neurologic symptoms resolved within two days [ 16 ].…”

Oral Administration of Penicillin or Streptomycin May Alter Serum Serotonin Level and Intestinal Motility via Different Mechanisms

“…Dysbiosis of the intestinal flora associated with antibiotic treatment may potentially alter the synthesis and the release of 5-HT from EC cells thereby impacting on host homeostasis, particularly the GI functions. Indeed, antibiotic exposure reportedly may either increase or decrease 5-HT availability, depending on types of antibiotics used and animal species studied ( Ge et al, 2017 ; Hasani et al, 2019 ). A better understanding of how antibiotic exposure may alter synthesis and release of 5-HT from EC cells may provide important insights on the prevention and management of adverse effects of antibiotics.…”