Résumé
Objectif: Présenter un cas de syndrome sérotoninergique (SS) retardé, un effet secondaire méconnu de certains antidépresseurs, pouvant survenir lors d’intoxication volontaire, en association avec la prise d’autres médicaments.
Éléments cliniques: Une patiente agée de 21 ans hospitalisée après une intoxication volontaire associant fluoxétine et benzodiazépines présentait un SS huit heures après son admission, les taux sanguins de fluoxétine étant alors à des valeurs thérapeutiques. La découverte d’une prise antérieure d’un inhibiteur de la monoamine oxydase (moclobémide) permettait d’expliquer la survenue de ce syndrome. Chez cette patiente, la sévérité du coma hypertonique a requis la ventilation mécanique en association avec une sédation combinant thiopental et fentanyl, et une myorelaxation avec le pancuronium.
Conclusion: La prise en charge de l’intoxication à la fluoxétine requiert une grande prudence, le risque majeur étant l’apparition d’un SS. Les formes graves de ce syndrome engagent le pronostic. Le traitement est symptomatique et peut nécessiter des mesures de réanimation. Les données de la littérature ne permettent pas de formuler des recommandations anesthésiques précises dans ces cas.
Abstract
Purpose: To present a case of delayed serotonin syndrome (SS), a less well-known adverse effect of fluoxetine intoxication.
Clinical presentation: A 21-yr-old woman was admitted following voluntary intoxication with fluoxetine and benzodiazepines. At the time of admission, she was slightly drowsy and hypotonic but, eight hours later, she developed severe hypertonic coma despite blood concentrations of fluoxetine within the therapeutic range. Repeated toxicological analyses revealed the presence of moclobemide at non-measurable concentrations, suggesting earlier ingestion of this monoamine oxydase inhibitor. Having excluded all other likely causes of the neurological syndrome observed, a SS was postulated. Treatment was symptomatic with mechanical ventilation, sedation with thiopental and fentanyl, and neuromuscular block with pancuronium bromide. The patient recovered spontaneously 20 hr later.
Conclusion: Physicians managing patients presenting with fluoxetine intoxication must be aware of the potential risk of SS. Treatment is symptomatic, but SS may be severe and require vital support in the intensive care environment. Review of published reports does not allow the authors to recommend a specific anesthetic management.
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Chambost, M., Liron, L., Peillon, D. et al. syndrome serotoninergique lors d’une intoxication par la fluoxetine chez une patiente prenant du moclobemide. ja]Can J Anaesth 47, 246–250 (2000). https://doi.org/10.1007/BF03018921
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DOI: https://doi.org/10.1007/BF03018921