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Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome

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Abstract

Introduction

Management of severe vasoplegic shock in overdose can be very challenging. We describe a case of severe refractory vasodilatory shock in poisoning where methylene blue (MB) was used with success. However, the patient subsequently developed severe Serotonin Syndrome (SS) as a result of an interaction between serotonergic drugs and MB.

Case Report

A 15-year-old male developed severe vasoplegic shock 1.5 hours after overdosing on several different medications including quetiapine slow release, quetiapine immediate release, desvenlafaxine slow release, venlafaxine, amlodipine, ramipril, fluoxetine, promethazine and lithium. His vasoplegic shock was resistant to high doses of noradrenaline and vasopressin. MB was administered 6.5 hours post ingestion and within 1 hour there was an improvement in his hemodynamic status and reduction of catecholamine requirements. Twelve hours post ingestion, he developed severe Serotonin Syndrome that lasted 5 days as a result of interaction between MB, a reversible monoamine oxidase inhibitor (MAO-I), and the antidepressants taken in overdose. MB had a calculated half-life of 38 hours.

Conclusion

MB is a useful additional strategy for severe drug induced vasodilatory shock and may be potentially life-saving. Clinicians should be aware that it can interact with other drugs and cause life-threatening Serotonin Syndrome. Lower doses or shorter durations may be wise in patients at risk of this interaction.

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Acknowledgements

The authors would like to thank Ms. Lorraine Mackenzie for her assistance in the analysis of the methylene blue samples.

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None.

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Authors and Affiliations

  1. Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia

    Betty S. Chan, Therese Becker & Angela L. Chiew

  2. School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia

    Ahmed M. Abdalla, Tom A. Robertson & Michael S. Roberts

  3. Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia

    Xin Liu & Michael S. Roberts

  4. Department of Clinical Pharmacology, University of Sydney, Sydney, New South Wales, Australia

    Nicholas A. Buckley

Authors
  1. Betty S. Chan
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  2. Therese Becker
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  3. Angela L. Chiew
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  4. Ahmed M. Abdalla
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  5. Tom A. Robertson
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  6. Xin Liu
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  7. Michael S. Roberts
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  8. Nicholas A. Buckley
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Corresponding author

Correspondence to Betty S. Chan.

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Consent for publication of this case was obtained from the family and provided to the journal in accordance with JMT policy.

Conflict of Interest

There is no conflict of interest to report.

Additional information

This case report was presented as a poster at the 37th International Congress of the European Association of Poison Centres and Clinical Toxicologists EAPCCT in Basel, May 2017.

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Chan, B.S., Becker, T., Chiew, A.L. et al. Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome. J. Med. Toxicol. 14, 100–103 (2018). https://doi.org/10.1007/s13181-017-0637-1

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  • DOI: https://doi.org/10.1007/s13181-017-0637-1

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