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Serotonin toxicity as a consequence of linezolid use in revision hip arthroplasty
Lyndon W Mason1, Kiran S Randhawa, Eleanor C Carpenter
1Department of Trauma and Orthopedic Surgery, University Hospital of Wales, Cardiff, Wales, United Kingdom.
Abstract:
Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicrobial, it has activity against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, penicillin-resistant Streptococcus pneumoniae, and macrolide-resistant streptococci. There are several documented case reports of serotonin toxicity when used with selective serotonin reuptake inhibitors. The symptoms of serotonin syndrome are alteration of mental state, autonomic dysfunction, and neuromuscular disorders. This article presents a case of an interaction of the serotonin reuptake inhibitor venlafaxine and linezolid and the possible diagnostic problems that can occur. A 58-year-old woman presented with signs of systemic infection. Her medical history included bladder resection for transitional cell carcinoma, bilateral total hip arthroplasty (THA), and depression, for which she was on venlafaxine. Serological and imaging investigations revealed MRSA infection of the bilateral THA. The patient was started on vancomycin and rifampicin intravenously. As intravenous access was becoming problematic and long-term antibiotics were needed, treatment was changed to oral linezolid and oral rifampicin. Four days after the commencement of linezolid, the patient was acutely disorientated with generalized cerebellar signs and no autonomic dysfunction. A computed tomography scan of the head and lumbar puncture revealed no abnormal findings. A diagnosis of serotonin toxicity was made. The patient recovered when linezolid and venlafaxine were discontinued and supportive measures were provided. Linezolid is a popular choice of antibiotic, especially for the treatment of orthopedic-related MRSA infections. Patients who commonly require linezolid as an antimicrobial are those with complex infections where other antibiotic treatment has failed. It is therefore important to be vigilant with linezolid use. Physicians should be aware of the nonspecific presentation of serotonin symptoms and the treatment.
Insights
Linezolid antibiotic use can cause serotonin toxicity, especially when combined with venlafaxine. Discontinuation of both drugs led to patient recovery, highlighting the need for physician vigilance.
Area of Science:
- Infectious Diseases
- Pharmacology
- Neurology
Background:
- Linezolid is a crucial antibiotic for treating resistant infections like MRSA.
- Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for depression.
- Serotonin syndrome is a potential adverse drug reaction associated with SSRIs.
Observation:
- A patient with MRSA hip infection on venlafaxine developed disorientation and cerebellar signs after starting linezolid.
- Initial investigations, including CT scan and lumbar puncture, were unremarkable.
- Symptoms resolved upon discontinuation of both linezolid and venlafaxine.
Findings:
- This case highlights a potential drug interaction between linezolid and venlafaxine, leading to serotonin toxicity.
- The patient's presentation mimicked other neurological conditions, posing diagnostic challenges.
- Prompt recognition and management, including drug cessation, were key to recovery.
Implications:
- Physicians must be aware of the risk of serotonin toxicity when prescribing linezolid, particularly in patients on SSRIs.
- Vigilance is required due to the nonspecific and potentially severe presentation of serotonin syndrome.
- This interaction underscores the importance of comprehensive medication review and patient monitoring.