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Case Report Highlights Variable Presentation of Serotonin Syndrome


October 26, 2018

She stated the pain was most prominent in her abdomen

She stated the pain was most prominent in her abdomen

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.”

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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. 

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Hydralazine-Induced Hepatotoxicity Described in Case Report


July 09, 2018

Laboratory testing revealed elevated liver enzymes which were initially attributed to amiodarone and atorvastatin

Laboratory testing revealed elevated liver enzymes which had been initially attributed to amiodarone and atorvastatin

A uncommon case of hepatotoxicity following the initiation of a brand new treatment to deal with poorly managed hypertension is described in a brand new case printed within the American Journal of Case Reviews.

The 74-year-old male affected person was began on hydralazine 2 months previous to presenting to the hospital with complaints of extreme nausea, dizziness, weak spot and right-upper quadrant belly ache. Laboratory testing revealed elevated liver enzymes which had been initially attributed to amiodarone and atorvastatin, nevertheless the affected person’s whole bilirubin continued to be excessive even after discontinuing these brokers. After extra testing dominated out different etiologies, the affected person was taken off of hydralazine which led to gradual scientific and biochemical restoration.

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Hydralazine, a phthalazine by-product, is believed to decrease blood stress by exerting a peripheral vasodilating impact by direct leisure of vascular easy muscle. Though usually an unusual aspect impact, hydralazine-induced hepatotoxicity can happen as early as 2–6 weeks after initiating remedy, with some studies indicating latency intervals starting from 2 months to 1 12 months.

Signs in sufferers with brief latency embody fever, rash, and eosinophilia, whereas in these with lengthy latency, persistent hepatitis and fibrosis has been famous. “Hydralazine hepatotoxicity has variable manifestation and might present a hepatocellular, cholestatic sample of harm, hypersensitivity, or autoimmune options,” the authors write. Discontinuing the agent usually results in reversal of hepatic harm inside a number of days to weeks. Re-challenge has been proven to lead to recurrence; on this case, the affected person was not re-challenged.

“Clinicians ought to pay attention to hydralazine-induced hepatotoxicity in order that such instances may be promptly recognized to advertise restoration,” concluded the authors, including “Any new incidence of hepatocellular harm after introduction of recent treatment needs to be rigorously evaluated.”

For extra data go to amjcaserep.com.

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Suicide Charges On the Rise in Almost Each State, Says New CDC Report

Both Kate Spade and Anthony Bourdain died this week from suicide.

Each Kate Spade and Anthony Bourdain died this week from suicide.

Suicide charges have elevated considerably within the US since 1999, in response to a brand new report launched by the Facilities for Illness Management and Prevention (CDC).

Utilizing knowledge from the Nationwide Important Statistics System, the CDC researchers examined developments in age-adjusted suicide charges in people 10 years of age and older, by state and intercourse, throughout 6 consecutive Three-year durations (1999–2016). Additionally they investigated contributing circumstances amongst suicide decedents with and with out recognized psychological well being situations utilizing knowledge from the Nationwide Violent Loss of life Reporting System (NVDRS) which lined 27 states in 2015.

Outcomes confirmed that suicide charges elevated by >30% in 25 states through the examine interval; practically all states (44) had been discovered to have important will increase. Greater than half of suicide decedents (54%) didn’t have a recognized psychological well being situation based mostly on NVDRS knowledge. Circumstances contributing to suicide included relationship issues/loss, substance use issues, well being issues, and job or monetary points.

“Suicide is a number one reason for demise for Individuals – and it is a tragedy for households and communities throughout the nation,” mentioned CDC Principal Deputy Director Anne Schuchat, MD, “From people and communities to employers and healthcare professionals, everybody can play a task in efforts to assist save lives and reverse this troubling rise in suicide.” The discharge of the CDC’s Important Indicators report occurred in per week the place two distinguished figures, designer Kate Spade and chef and tv presenter Anthony Bourdain, each had been reported to have died from suicide.

Case Report Reveals One other Attainable Aspect Impact of Kratom


March 26, 2018

According to the authors, this is the first report of kratom-induced hyperprolactinemia

In accordance with the authors, that is the primary report of kratom-induced hyperprolactinemia

A current case report highlights one more potential aspect impact associated to the ingestion of the botanical substance, kratom. The controversial plant, utilized by some as an opioid substitute, has turn into more and more obtainable within the U.S. and is on the heart of a present multistate Salmonella outbreak. 

On this case, a 42-year previous male complaining of low power and poor libido was discovered to have mildly elevated serum prolactin (24ng/mL [upper limit=12ng/mL]) with hypogonadotropic hypogonadism. Additional testing revealed no pituitary pathology or hypothyroidism; the affected person was not taking any medicines and reported no use of androgenic steroids or leisure medicine.

At a follow-up 2 months later, his prolactin stage was 6ng/mL and his whole testosterone stage was additionally again within the regular vary. The affected person then admitted to kratom use earlier than his preliminary go to, which he stopped just a few days after that first go to.  

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In accordance with the authors, this case is believed to be the primary to report on hyperprolactinemia related to kratom ingestion. The situation often presents with signs of hypogonadism in each women and men. Ladies are inclined to report signs earlier resulting from adjustments in menstrual cycles whereas signs might not be as distinct for male sufferers.

Whereas dopamine agonists, serotonin reuptake inhibitors, antipsychotics, and opioids all have the potential to extend prolactin ranges, the affected person had not been taking any of those medicines throughout his preliminary presentation. Provided that the affected person’s serum prolactin and testosterone normalized after discontinuing kratom, the authors concluded that “this sequence strongly suggests kratom consumption was causally associated to the change in serum prolactin stage” on this affected person.  

At the moment, kratom stays authorized within the U.S. however the Meals and Drug Administration (FDA) is actively halting unlawful imports as there aren’t any FDA-approved therapeutic makes use of. The drug is derived from the leaves of the Mitragyna speciose tree, native to southeast Asia.

For extra info go to Sagepub.com.

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