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Case Report/Case Series |

Serotonin Syndrome Associated With Clozapine Withdrawal

Elizabeth Stevenson, MD, MS1; Frank Schembri, MD1; Deborah M. Green, MD2,3; Joseph D. Burns, MD2,3
[+] Author Affiliations
1Department of Pulmonary Critical Care, Boston Medical Center, Boston University School of Medicine, Massachusetts
2Department of Neurology, Boston Medical Center, Boston University School of Medicine, Massachusetts
3Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, Massachusetts
JAMA Neurol. 2013;70(8):1054-1055. doi:10.1001/jamaneurol.2013.95.
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Importance  We describe a case of serotonin syndrome secondary to clozapine withdrawal and concomitant use of citalopram hydrobromide, a phenomenon that has been rarely reported.

Observations  This is a case report of a 47-year-old woman admitted to an academic medical center intensive care unit with coma, hypersalivation, hyperreflexia, and stimulus-induced clonus. The patient received a diagnosis of serotonin syndrome attributed to abrupt clozapine withdrawal with concomitant use of citalopram. She improved only minimally with supportive treatment (intravenous fluids, benzodiazapines, and withdrawal of selective serotonin-reuptake inhibitor) and received cyproheptadine hydrochloride on her third day of symptoms. Four hours after she received the loading dose of cyproheptadine, she was alert and oriented and at her baseline mental status, although some clonus remained.

Conclusions and Relevance  Serotonin syndrome can result from the abrupt withdrawal of a 5-hydroxytryptamine receptor 2A antagonist from a treatment regimen that also includes a medication that increases serotonin availability.

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