Nemet Marko, Andrijević Ana, Nedeljkov Đorđe, Andrić Vladimir, Gavrilović Srđan
Internal Medicine, University of Novi Sad, Novi Sad, SRB.
Intenisve Care Unit, Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, SRB.
Cureus. 2023 Mar 28;15(3):e36780. doi: 10.7759/cureus.36780. eCollection 2023 Mar.
Patients with Parkinson's disease are often at risk of polypharmacy, which can lead to serious medication side effects and interactions. Serotonin syndrome (SS) can develop in this patient population due to a possible drug-drug interaction between antidepressants and antiparkinson drugs with serotoninergic activity. On the other hand, these patients are also at risk of malignant syndrome (MS) secondary to dopaminergic medication withdrawal. In this case report, we present a 71-year-old female with Parkinson's disease who developed symptoms suggestive of SS. The patient was admitted to the medical intensive care unit at the Institute for Pulmonary Diseases of Vojvodina in the Republic of Serbia due to impaired consciousness and a previously witnessed cardiorespiratory arrest. Her chronic antiparkinson medication regimen consisted of levodopa, benserazide, entacapone, ropinirole, and rasagiline. Furthermore, she had been prescribed duloxetine for a remote history of depression, which she had only been taking intermittently. Several days before admission, however, the patient started taking duloxetine again due to low mood. Upon admission, laboratory tests revealed leukocytosis with neutrophilia, elevated C-reactive protein, procalcitonin, lactate, urea, and creatinine. Serum creatine kinase (CK) levels were also elevated at 1250 U/L. Six hours after admission to the ICU, the patient developed hyperthermia, hyperreflexia, spontaneous myoclonus, and tremors. Her CK levels continued to rise, reaching 6900 U/L, and her renal function worsened. Due to the possibility of either SS or MS, external cooling measures with frozen gel packs were administered, resulting in the patient's stabilization over a few hours. Further, serotoninergic medication (rasagiline and duloxetine) was discontinued. On the fifth day of hospitalization, a head CT showed signs of cytotoxic edema. On the 11th day, the patient became hemodynamically unstable and passed away despite all adequate resuscitative measures. The purpose of this case report is to raise awareness of possible SS in patients taking monoamine oxidase-B (MAO-B) inhibitors such as rasagiline. Clinicians should have a high index of suspicion for this complication, especially in patients who are treated for comorbid depression with serotoninergic drugs. Furthermore, we emphasize the importance of correctly differentiating SS from MS, which are both risks for patients with Parkinson's disease. A correct approach to these patients is of utmost importance for adequate management and optimal outcomes.
帕金森病患者常常面临多重用药风险，这可能导致严重的药物副作用及相互作用。5-羟色胺综合征（SS）可能在这类患者群体中发生，原因是抗抑郁药与具有5-羟色胺能活性的抗帕金森病药物之间可能存在药物相互作用。另一方面，这些患者还存在因停用多巴胺能药物继发恶性综合征（MS）的风险。在本病例报告中，我们介绍了一名71岁患帕金森病的女性，她出现了提示SS的症状。该患者因意识障碍及此前曾发生的心搏呼吸骤停被收入塞尔维亚共和国伏伊伏丁那肺病研究所的医学重症监护病房。她的慢性抗帕金森病药物治疗方案包括左旋多巴、苄丝肼、恩他卡朋、罗匹尼罗和雷沙吉兰。此外，她曾因既往有抑郁症病史而服用度洛西汀，但只是间断服用。然而，入院前几天，患者因情绪低落再次开始服用度洛西汀。入院时，实验室检查显示白细胞增多伴中性粒细胞增多、C反应蛋白、降钙素原、乳酸、尿素和肌酐升高。血清肌酸激酶（CK）水平也升高至1250 U/L。入住重症监护病房6小时后，患者出现高热、反射亢进、自发性肌阵挛和震颤。她的CK水平持续升高，达到6900 U/L，肾功能恶化。由于可能是SS或MS，采用了用冷冻凝胶袋进行外部降温措施，患者在数小时内病情稳定。此外，停用了5-羟色胺能药物（雷沙吉兰和度洛西汀）。住院第5天，头部CT显示细胞毒性水肿迹象。第11天，患者血流动力学不稳定，尽管采取了所有充分的复苏措施仍死亡。本病例报告的目的是提高对服用如雷沙吉兰等单胺氧化酶-B（MAO-B）抑制剂的患者可能发生SS的认识。临床医生应对此并发症保持高度怀疑指数，尤其是对同时接受5-羟色胺能药物治疗合并抑郁症的患者。此外，我们强调正确区分SS与MS的重要性，这两者都是帕金森病患者面临的风险。对这些患者采取正确的处理方法对于充分管理和取得最佳治疗效果至关重要。
