Table 2 Timeline of development of symptoms and management
Time | Symptoms | Management |
|---|---|---|
Day 1 8:33 a.m. | After taking SNRI, hot flush, stiffness around the neck and shoulder, diaphoresis, and muscle rigidity in the masseter appeared. BP 112/78 mmHg, 77 bpm, BT 37.4 °C | Body cooling Intravenous administration of dantrolene 40 mg for muscle rigidity. No abnormalities were found in the blood test. |
   10:10 | No raise in serum serotonin level (4 ng/ml) | Diagnosed as serotonin syndrome Serotonergic agents (duloxetine and mirtazapine) were stopped immediately. |
   12:45 | Myoclonus and tremor on the upper extremities. Tachycardia (120 bpm) and diaphoresis |  |
   13:00 | Myoclonic seizures on the upper extremities and neck. Tachycardia (140 bpm), BP 162/102 mmHg, respiratory rate 28/min |  |
   13:20 | Myoclonic seizures on the shoulders and neck. Tachycardia (140 bpm), BP 169/120 mmHg, respiratory rate 35/min | Admitted to the intensive care unit. Clonazepam 1.0 mg (per oral), intralipid (20%) 100 ml, and started landiolol 0.01 mg/kg/min |
   16:10 | No myoclonus was seen after the initial dose of cyproheptadine. Vital was stabilized soon. | Cyproheptadine 12 mg (per oral) |
   22:00 |  | Cyproheptadine 4 mg (per oral) |
Day 2 6:00 |  | Cyproheptadine 4 mg (per oral) Moved to general ward |
Day 4 | Â | Discharged from the hospital |