In a recently published case report describing a 50-year-old female patient with chronic kidney disease, the variable presentation of serotonin syndrome was discussed and the importance of early recognition highlighted.
According to the report, the patient presented to the emergency department complaining of nausea and diffuse body pain. She stated the pain was most prominent in her abdomen, began the evening before, and had worsened since. The patient’s past medical history was significant for chronic kidney disease (stage 5) on nightly peritoneal dialysis, type 2 diabetes mellitus, peripheral neuropathy, gastroesophageal reflux disease, hypertension, and chronic pain.
During physical examination she complained of pain upon light palpitation but was otherwise unremarkable. Laboratory results showed elevated levels of liver transaminases, blood urea nitrogen, and creatinine. Computed tomography with IV contrast of her abdomen revealed “wedge-shaped areas of hypodensity in the spleen.”
During the first 3 days of her hospital stay, the patient complained of worsening pain, nausea, retching, diarrhea, and vomiting. Her symptoms continued despite trials of ondansetron and promethazine. “She also had episodic hypertension, with systolic blood pressure as high as 234 mmHg,” the study authors commented, adding, “She continued to display asterixis, and on day 3 of hospitalization, she was found to have inducible clonus and new patellar hyperreflexia bilaterally.”
Upon review of her medications, it was found that the patient was taking multiple serotonergic agents. In addition to the ondansetron prescribed during her hospital stay, the patient was taking duloxetine twice daily and tramadol as needed at home. The patient was diagnosed with serotonin syndrome and all serotonergic medications were discontinued. The patient’s symptoms resolved over the course of 4 days.
“It is important to recognize serotonin syndrome early, as symptomatic treatment of its symptoms may involve use of medications that will greatly worsen the condition,” the study authors concluded. “Diffuse body pain may be an initial presentation of serotonin syndrome.”
Guo MH, Monir RL, Wright A, Holland NP. Case of Serotonin Syndrome Initially Presenting as Diffuse Body Pain. Am. Journal of Case Reports. DOI: 10.12659/AJCR.911204. 2018.