Abstract
Introduction
Although medication toxicity is uncommon in neonates, there are several medications used in this population that pose a risk. Phenytoin has an increased risk of toxicity given its narrow therapeutic window and variations in drug elimination.
Case Report
We describe the case of a 3-day-old male infant who developed cardiovascular collapse secondary to severe phenytoin toxicity (max phenytoin level 86 μg/mL) and was placed on extracorporeal membrane oxygenation support (ECMO). Several ancillary treatments were utilized in an attempt to decrease serum phenytoin concentrations and limit toxicity including albumin boluses, phenobarbital administration, intravenous lipid infusion, and folic acid supplementation.
Discussion
Although uncommon, drug toxicity should be considered in patients with acute changes who are exposed to medications with potential toxicity. With elevated levels of phenytoin, the half-life can be prolonged resulting in longer exposure to elevated levels of the drug as seen in our patient. This case report highlights the importance of ECMO utilization for cardiac support in neonates with medication toxicity and other potential ancillary treatments to decrease serum phenytoin concentrations.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Craig S. Phenytoin poisoning. Neurocrit Care. 2005;3(2):161–70. https://doi.org/10.1385/NCC:3:2:161.
Anseeuw K, Mowry JB, Burdmann EA, Ghannoum M, Hoffman RS, Gosselin S, et al. Extracorporeal treatment in phenytoin poisoning: systematic review and recommendations from the EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup. Am J Kidney Dis. 2016;67(2):187–97. https://doi.org/10.1053/j.ajkd.2015.08.031.
Wang GS, Levitan R, Wiegand TJ, Lowry J, Schult RF, Yin S, et al. Extracorporeal membrane oxygenation (ECMO) for severe toxicological exposures: review of the toxicology investigators consortium (ToxIC). J Med Toxicol. 2016;12(1):95–9. https://doi.org/10.1007/s13181-015-0486-8.
El-Dib M, Soul JS. The use of phenobarbital and other anti-seizure drugs in newborns. Semin Fetal Neonatal Med. 2017;22(5):321–7. https://doi.org/10.1016/j.siny.2017.07.008.
Adams BD, Buckley NH, Kim JY, Tipps LB. Fosphenytoin may cause hemodynamically unstable bradydysrhythmias. J Emerg Med. 2006;30(1):75–9. https://doi.org/10.1016/j.jemermed.2005.01.034.
Keegan MT, Bondy LR, Blackshear JL, Lanier WL. Hypocalcemia-like electrocardiographic changes after administration of intravenous fosphenytoin. Mayo Clin Proc. 2002;77(6):584–6. https://doi.org/10.4065/77.6.584.
Leeder JS, Kearns GL. Pharmacogenetics in pediatrics. Implications for practice. Pediatr Clin N Am. 1997;44(1):55–77.
Eren Cevik S, Tasyurek T, Guneysel O. Intralipid emulsion treatment as an antidote in lipophilic drug intoxications. Am J Emerg Med. 2014;32(9):1103–8. https://doi.org/10.1016/j.ajem.2014.05.019.
Seligmann H, Potasman I, Weller B, Schwartz M, Prokocimer M. Phenytoin-folic acid interaction: a lesson to be learned. Clin Neuropharmacol. 1999;22(5):268–72.
Veeravigrom M, Jaroonvanichkul V, Netbaramee W, Phaisarn P, Uyathanarat T. Phenytoin toxicity in two-month-old Thai infant with CYP2C9 gene polymorphism--a case report. Brain and Development. 2016;38(1):136–8. https://doi.org/10.1016/j.braindev.2015.05.001.
Acknowledgments
We would like to thank the family of this patient for allowing us to share his story. We would also like to thank the numerous providers at Children’s Hospital of New Orleans who helped us care for this infant.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Consent for publication of this case was obtained and provided to the journal in accordance with JMT policy.
Conflict of Interest
None.
Additional information
Supervising Editor: Katherine O'Donnell, MD
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Knecht, M., LaRochelle, J., Barkemeyer, B. et al. Cardiac Collapse Secondary to Phenytoin Toxicity in a Neonate Treated with Extracorporeal Membrane Oxygenation Support (ECMO). J. Med. Toxicol. 16, 230–235 (2020). https://doi.org/10.1007/s13181-019-00742-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13181-019-00742-x