708 - Serotonin Syndrome in Pediatric Brain Injury: A Common Risk?

SM is a 15-year-old, previously healthy female, who developed acute encephalitis of unclear etiology with necrotic brain lesions and cystic encephalomalacia. She was admitted to inpatient rehab for prolonged disorder of consciousness (DOC) program and underwent a comprehensive neurorehabilitation program, during which she emerged from DOC. 

During her rehab course, SM developed acute onset of fever, tachycardia, and increased tone concerning for shock. At the time, there was a lower concern for sepsis given no clear source of infection on exam including no indwelling lines or hardware, low inflammatory markers, and negative cultures. Ultimately, her clinical presentation was thought to be in the setting of serotonin syndrome with recent addition of a SSRI and recent administration to fentanyl in addition to standing serotonergic medications, methylphenidate for arousal, and Trazadone for sleep. Once these agents were discontinued and she was started on low dose IV valium and cyproheptadine symptoms resolved.   




Discussions: Serotonin syndrome, though rare, can be life-threatening.  Symptoms include mental status changes, tachycardia, hypertension, fevers, muscle rigidity, myoclonus, hyperreflexia, and worsening spasticity.  Diagnosis is primary clinical with recognition of above symptoms in the setting of serotonergic medications.  

Conclusions: Early recognition and treatment of serotonin syndrome is crucial to avoid severe complications. Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), Stimulants, and analgesic drugs including fentanyl are commonly associated with serotonin syndrome as well as a lower incidence is seen with Trazadone. Pediatric brain injury often uses these medications to address common problems including arousal, mood, and sleep. Including serotonin syndrome in your differential is essential for early recognition.