Sertraline/tramadol

Abstract

A 38-year-old woman developed serotonin syndrome during treatment with sertraline as an anxiolytic and tramadol for pain [routes not stated].The woman, who had nonverbal autism, epilepsy and intellectual disability, was admitted to the hospital due to severe Pica behaviour for three years. She had a history of vitamin B9 deficiency, iron deficiency and gastric ulcer. Following a period of observation, a problematic behaviour was observed, which involved ingestion of inedible foreign objects. She required constant monitoring. Investigations revealed a gastric bezoar with multiple plastic foreign bodies. The bezoar could not be removed, because of a technical problem. During the course of hospitalisation, she started receiving sertraline 50 mg/day as anxiolytic along with sodium valproate, diazepam, melatonin, sodium alginate/sodium bicarbonate, lansoprazole and phloroglucinol. After a few weeks, she underwent an intensive behavioural therapy. However, there was deterioration of her general condition. Her compulsive motor activity had intensified, she had pain on abdominal palpation along with diarrhoea. A subocclusive syndrome secondary to severe Pica behaviour was presumed, and she underwent a colonic lavage with polyethylene glycol that allowed the elimination of a medical compress. She started receiving tramadol 225 mg/day for pain. During this episode, the biological assessment revealed an inflammatory syndrome, disturbance of the hepatic assessment, iron deficiency anaemia, cardiac injury and rhabdomyolysis. The viral PCR was positive for coronavirus OC-43. After a day, she presented with profuse sweating. Modified physiological constants were as follows: peripheral temperature 38.2°C, HR 150 beats/minute, systolic arterial pressure 130mm Hg and oxygen saturation in ambient air 91%. During the night, she had several desaturations. The following morning, she was found in a calm coma with a Glasgow score of 3. She was shifted to the ICU. On basis of the investigations, her condition was consistent with serotonin syndrome. Serotonin syndrome was attributed to sertraline and tramadol [duration of treatments to reaction onset not stated].The woman was treated with naloxone, and she responded immediately. Following an immediate response to opioid antidote, tramadol overdose was hypothesised. It was presumed that the presence of gastric bezoar slowed the absorption of tramadol, which led to the overdose of tramadol. After a few hours of antidote administration, she became fully vigilant and her outcome was favourable. She was transferred back to neurodevelopmental unit. After 2 weeks, she underwent an exploratory laparotomy to remove the bezoar. However, bezoar was not detected, the small intestine was not dilated and there was no stenosis. A gastroscopy revealed a free stomach. Spontaneous elimination of foreign bodies was concluded. Following treatment of anaemia by iron supplementation and intensive behavioural therapy, there was an improvement in her Pica behaviour.