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Amitriptyline-associated seizures in a toddler with Munchausen-by-proxy
M E Mullins1, C B Cristofani, C R Warden
1Oregon Poison Center and Department of Emergency Medicine, Oregon Health Sciences University, Portland 97201-3098, USA. mullinmi@ohsu.edu
Insights
A toddler
Area of Science:
- Pediatric Neurology
- Clinical Toxicology
Background:
- Idiopathic seizures are common in toddlers.
- Accurate diagnosis is crucial for appropriate treatment.
Observation:
- A toddler presented with recurrent seizures, initially diagnosed as idiopathic epilepsy.
- Electrocardiogram (EKG) showed widened QRS and right axis deviation.
- Despite multiple admissions, the cause remained undiagnosed.
Findings:
- The seizures were deliberately induced by amitriptyline poisoning administered by a custodian.
- Classic signs of cyclic antidepressant poisoning were overlooked.
- Misdiagnosis was facilitated by the assumption of epilepsy in patients with seizures.
Implications:
- Highlights the importance of considering toxicological causes in unexplained seizures, even with a prior epilepsy diagnosis.
- Underscores the need for thorough investigation of cyclic antidepressant poisoning.
- Emphasizes the diagnostic challenges posed by non-accidental poisoning in pediatric patients.
Abstract:
We describe an unusual case of a toddler diagnosed with an idiopathic seizure disorder that later was proved to be caused by deliberate administration of amitriptyline by his custodian. In spite of seizures associated with widened electrocardiographic wave (QRS) and right axis deviation on the electrocardiogram (EKG), the correct diagnosis eluded clinicians through a series of hospital admissions. Unfortunately, clinicians are quite accustomed to the fact that patients previously diagnosed with epilepsy have seizures and may not investigate other causes of seizure. This allowed classic signs of cyclic antidepressant poisoning to go unrecognized.