SHM Converge Scientific Abstract ePoster Gallery-A Case of the Shakes: Serotonin Syndrome Associated With Tramadol

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This case report describes a 66-year-old man with hepatocellular carcinoma, bipolar disorder, and gout who developed serotonin syndrome after increased tramadol use for gout pain. Over two weeks, he had been taking tramadol every six hours and presented with lightheadedness, syncope, tremulousness, and confusion. On exam, he was diaphoretic, restless, and had diffuse tremors with increased tone and rigidity in all extremities. His vital signs showed mild tachycardia, and labs revealed severe rhabdomyolysis with a creatine phosphokinase level of 80,000 U/L, along with kidney injury and elevated liver enzymes.<br /><br />Toxicology was consulted, and serotonin syndrome was suspected due to tramadol monotherapy. He was treated with IV fluids, cyproheptadine, and lorazepam as needed. His symptoms improved, laboratory values trended downward, and tramadol was stopped before discharge.<br /><br />The report highlights that serotonin syndrome is caused by excessive serotonergic activity and typically presents with neuromuscular hyperactivity and autonomic instability. Tramadol, although often perceived as a safer opioid option, can independently trigger serotonin syndrome and seizures. The patient’s hepatocellular carcinoma may have reduced tramadol metabolism, increasing his risk of toxicity.<br /><br />A key teaching point is the importance of recognizing serotonin syndrome early, especially in hospitalized patients receiving tramadol. Prompt discontinuation of the offending drug and supportive management are essential. The case also contrasts serotonin syndrome with neuroleptic malignant syndrome: serotonin syndrome usually develops within hours to days and features tremor, hyperreflexia, and myoclonus, whereas neuroleptic malignant syndrome develops over days to weeks and is characterized by rigidity and bradyreflexia.

Asset Subtitle

Helpees Guirguis

Meta Tag

Author List Helpees Guirguis, Sherry Zhang

Category Clinical Vignettes

Concept Serotonin Syndrome

Concept Tramadol

Concept Drug Discontinuation

Concept Serotonergic Excess

Concept Neuromuscular Irritability

Distinguished Non-Finalist

Presenter Organization University of California San Diego

Presenting Author Helpees Guirguis

Track Adult

Keywords

serotonin syndrome

tramadol

rhabdomyolysis

hepatocellular carcinoma

cyproheptadine

lorazepam

neuromuscular hyperactivity

autonomic instability

kidney injury

neuroleptic malignant syndrome

Serotonin Syndrome

Tramadol

Drug Discontinuation

Serotonergic Excess

Neuromuscular Irritability