Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc
Journal website

Case Report

Volume 7, Number 12, December 2016, pages 554-557

Serotonin Syndrome Induced by Combined Use of Tramadol and Escitalopram: A Case Report


Figure 1.
Figure 1. Hunter’s decision rules for diagnosis of serotonin toxicity [12].


Table 1. Examples of Medicines With Potential to Cause Serotonin Syndrome [3, 6-8]
Therapeutic groupExamples of medicines
SSRI antidepressantsCitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
SNRI antidepressantsVenlafaxine, duloxetine
MAOI antidepressantsTranylcypromine, phenelzine, moclobemide (reversible MAO-A inhibitor), isocarboxazid
Tricyclic antidepressantsClomipramine, imipramine
MiscellaneousLithium, trazodone, L-tryptophan
OpioidsPethidine, tramadol, methadone, fentanyl, dextromethorphan, dextropropoxyphene, pentazocine, oxycodone
Parkinson’s disease treatmentSelegiline (selective MAO-B inhibitor)
AntibacterialsLinezolid (reversible MAOI activity)
Anti-cancer drugsProcarbazine
AnticonvulsantsCarbamazepine, valproate
AntiemeticsPromethazine, metoclopramide, ondansetron
Antimigraine drugsTriptans, e.g. frovatriptan, almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan. Dihydroergotamine
Anti-smoking aidsBupropion
Diagnostic dyeMethylthioninium chloride (methylene blue) (15) has reversible MAOI activity (16)
Herbal productsSt John’s wort
Street drugsCocaine, LSD


Table 2. Differential Diagnosis of Serotonin Syndrome [11-14]
Clinical conditionHistoryVital signsClinical features
Anticholinergic syndromeUse of tricyclic antidepressants or other anticholinergic drugsTachycardia, tachypnea, hyperthermia (usually 102.2 °F (39 °C) or below)Dry mouth, blurred vision, mydriasis, flushed skin, agitation/delirium, decreased bowel sounds
Malignant hyperthermiaAdministration of halogenated inhalational anesthetics or depolarizing muscle relaxantsHypertension, tachycardia, tachypnea, hyperthermia (up to 114.8 °F (46 °C))Diaphoresis, mottled skin, agitation, decreased bowel sounds, muscular rigidity, hyporeflexia
Neuroleptic malignant syndrome [11-14]Ingestion of antipsychotic medicationsHypertension, tachycardia, tachypnea, hyperthermia (above 105.8 °F (41 °C))Sialorrhea, diaphoresis, pallor, stupor, mutism, coma, normal or decreased bowel sounds, lead-pipe rigidity, bradyreflexia