Serotonin syndrome

Short description: Symptoms caused by an excess of serotonin in the central nervous system

Not to be confused with SSRI discontinuation syndrome.

Serotonin syndrome

Other names| Serotonin toxicity, serotonin toxidrome, serotonin sickness, serotonin storm, serotonin poisoning, hyperserotonemia, serotonergic syndrome, serotonin shock
Serotonin
Specialty| Critical care medicine, psychiatry
Symptoms| High body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, diarrhea[1][2]
Usual onset| Within a day[2]
Causes| Selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI), monoamine oxidase inhibitor (MAOI), tricyclic antidepressants (TCAs), amphetamine, methylene blue, pethidine (meperidine), tramadol, dextromethorphan, ondansetron, cocaine[2]
Diagnostic method| Based on symptoms and medication use[2]
Differential diagnosis| Neuroleptic malignant syndrome, malignant hyperthermia, anticholinergic toxicity, heat stroke, meningitis[2]
Treatment| Active cooling[1]
Medication| Benzodiazepines, cyproheptadine[1]
Frequency| Unknown[3]

Serotonin syndrome (SS) is a group of symptoms that may occur with the use of certain serotonergic medications or drugs.[1] The symptoms can range from mild to severe, and are potentially fatal.[4][5][2] Symptoms in mild cases include high blood pressure and a fast heart rate; usually without a fever.[2] Symptoms in moderate cases include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea.[1][2] In severe cases, body temperature can increase to greater than 41.1 °C (106.0 °F).[2] Complications may include seizures and extensive muscle breakdown.[2]

Serotonin syndrome is typically caused by the use of two or more serotonergic medications or drugs.[2] This may include selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI), monoamine oxidase inhibitor (MAOI), tricyclic antidepressants (TCAs), amphetamines, pethidine (meperidine), tramadol, dextromethorphan, buspirone, L-tryptophan, 5-hydroxytryptophan, St. John's wort, triptans, MDMA, metoclopramide, or cocaine.[2] It occurs in about 15% of SSRI overdoses.[3] It is a predictable consequence of excess serotonin on the central nervous system.[6] Onset of symptoms is typically within a day of the extra serotonin.[2]

Diagnosis is based on a person's symptoms and history of medication use.[2] Other conditions that can produce similar symptoms such as neuroleptic malignant syndrome, malignant hyperthermia, anticholinergic toxicity, heat stroke, and meningitis should be ruled out.[2] As of 2013, no laboratory tests exist that can confirm the diagnosis.[2]

Initial treatment consists of discontinuing medications which may be contributing.[1] In those who are agitated, benzodiazepines may be used.[1] If this is not sufficient, a serotonin antagonist such as cyproheptadine may be used.[1] In those with a high body temperature, active cooling measures may be needed.[1] The number of cases of serotonin syndrome that occur each year is unclear.[3] With appropriate medical intervention the risk of death is low, likely less than 1%.[7] The high-profile case of Libby Zion, who is generally accepted to have died from serotonin syndrome, resulted in changes to graduate medical school education in New York State.[6][8]

## Contents

* 1 Signs and symptoms
* 2 Causes
* 3 Pathophysiology
* 3.1 Spectrum concept
* 4 Diagnosis
* 4.1 Differential diagnosis
* 5 Management
* 5.1 Agitation
* 5.2 Hyperthermia
* 6 Prognosis
* 7 Epidemiology
* 8 History
* 9 Notable cases
* 10 See also
* 11 References
* 12 External links

## Signs and symptoms

File:ClonusfromSS (edited).webm

Symptom onset is usually relatively rapid, and serotonin syndrome encompasses a wide range of clinical findings. Mild symptoms may consist of increased heart rate, shivering, sweating, dilated pupils, and myoclonus (intermittent jerking or twitching), as well as hyperreflexia (overresponsive reflexes).[6] Many of these symptoms may be side effects of the drug or drug interaction causing excessive levels of serotonin rather than an effect of elevated serotonin itself.

Tremor is a common side effect of MDMA's action on dopamine, whereas hyperreflexia is symptomatic of exposure to serotonin agonists. Moderate intoxication includes additional abnormalities such as hyperactive bowel sounds, high blood pressure and hyperthermia; a temperature as high as 40 °C (104 °F). The overactive reflexes and clonus in moderate cases may be greater in the lower limbs than in the upper limbs. Mental changes include hypervigilance or insomnia and agitation.[6] Severe symptoms include severe increases in heart rate and blood pressure. Temperature may rise to above 41.1 °C (106.0 °F) in life-threatening cases. Other abnormalities include metabolic acidosis, rhabdomyolysis, seizures, kidney failure, and disseminated intravascular coagulation; these effects usually arising as a consequence of hyperthermia.[6][9]

The symptoms are often present as a clinical triad of abnormalities and can be used to assess the severity of serotonin syndrome:[6][10]

Serotonin syndrome severity assessment scale[6][10] Severity  | Autonomic effects  | Neurological (somatic) signs  | Mental status  | Other symptoms

|
|
|
|

mild  |

* absent or low-grade fever
* tachycardia
* mydriasis
* excessive sweating
* shivering

* intermittent tremor
* akathisia
* myoclonus
* mild hyperreflexia

* restlessness
* anxiety

moderate  |

* increased tachycardia
* fever up to 41 °C
* nausea
* diarrhea
* hyperactive bowel sounds
* excessive sweating
* vasoconstriction

* moderate hyperreflexia
* inducible clonus
* ocular clonus (slow continuous eye movements)
* myoclonus (muscle twitching)

* easily induced startle response
* confusion
* agitation
* hypervigilance

* rhabdomyolysis
* metabolic acidosis
* renal failure
* disseminated intravascular coagulopathy

severe  |

* temperature higher than 41 °C (caused by increased muscle tone)

* increased muscle tone, which is more severe in lower limbs
* spontaneous clonus
* intense myoclonus
* severe hyperreflexia

* delirium
* coma

| as above

## Causes

Numerous medications and street drugs can cause serotonin syndrome when taken alone at high doses or in combination with other serotonergic agents. The table below lists some of these.

Class  | Drugs that can induce serotonin syndrome

|

Antidepressants | Monoamine oxidase inhibitors (MAOIs),[6] tricyclic antidepressants (TCAs),[6] SSRIs,[6] SNRIs,[6] nefazodone,[11] trazodone[11]
Opioids | Dextropropoxyphene,[12] tramadol,[6] tapentadol, pethidine (meperidine),[6] fentanyl,[6] pentazocine,[6] buprenorphine[13] oxycodone,[14] hydrocodone[14]
Stimulants and entactogens  | MDMA,[6] MDA,[6] AMT,[15] caffeine,[16] methamphetamine,[17] lisdexamfetamine,[18] amphetamine,[19] phentermine,[12] amfepramone (diethylpropion),[12] sibutramine,[6] methylphenidate,[12] cocaine[12]
5-HT1 agonists  | Triptans[6][12]
Psychedelics
Herbs  | St John's wort,[6] Syrian rue,[6] Panax ginseng,[6] nutmeg,[20] yohimbe[21]
Others  | Tryptophan,[6] L-DOPA,[22] valproate,[6] buspirone,[6] lithium,[6] linezolid,[6][23] dextromethorphan,[6] 5-hydroxytryptophan,[11] chlorpheniramine,[12] risperidone,[24] olanzapine,[25] ondansetron,[6] granisetron,[6] metoclopramide,[6] ritonavir,[6] metaxalone,[6] methylene blue[26]

Many cases of serotonin toxicity occur in people who have ingested drug combinations that synergistically increase synaptic serotonin.[10] It may also occur due to an overdose of a single serotonergic agent.[27] The combination of monoamine oxidase inhibitors (MAOIs) with precursors such as L-tryptophan or 5-hydroxytryptophan pose a particularly acute risk of life-threatening serotonin syndrome.[28] The case of combination of MAOIs with tryptamine agonists (commonly known as ayahuasca) can present similar dangers as their combination with precursors, but this phenomenon has been described in general terms as the cheese effect. Many MAOIs irreversibly inhibit monoamine oxidase. It can take at least four weeks for this enzyme to be replaced by the body in the instance of irreversible inhibitors.[29] With respect to tricyclic antidepressants (TCAs), only clomipramine and imipramine have a risk of causing serotonin syndrome.[30]

Many medications may have been incorrectly thought to cause serotonin syndrome. For example, some case reports have implicated atypical antipsychotics in serotonin syndrome, but it appears based on their pharmacology that they are unlikely to cause the syndrome.[31] It has also been suggested that mirtazapine has no significant serotonergic effects and is therefore not a dual action drug.[32] Bupropion has also been suggested to cause serotonin syndrome,[33][34] although as there is no evidence that it has any significant serotonergic activity, it is thought unlikely to produce the syndrome.[35] In 2006 the US Food and Drug Administration (FDA) issued an alert suggesting that the combined use of either SSRIs or SNRIs with triptan medications or sibutramine could potentially lead to severe cases of serotonin syndrome.[36] This has been disputed by other researchers, as none of the cases reported by the FDA met the Hunter criteria for serotonin syndrome.[36][37] The condition has however occurred in surprising clinical situations, and because of phenotypic variations among individuals, it has been associated with unexpected drugs, including mirtazapine.[38][39]

Despite acting as non-selective serotonin receptor agonists, major serotonergic psychedelics like lysergic acid diethylamide (LSD) and psilocybin do not cause serotonin syndrome even in the context of extreme overdose.[40][41][42] This is thought to be due to the fact that they act as partial agonists of serotonin receptors like the serotonin 5-HT2A receptor, in contrast to serotonin itself which is a full agonist.[40][42] Combination of psychedelics like LSD and psilocybin with antidepressants such as SSRIs is also not thought to pose a risk of serotonin syndrome.[42] A 2018 retrospective analysis of 3,554 LSD-only exposures reported to poison control centers in the United States between 2000 and 2016 found that serious toxicity was infrequent.[41][43] On the other hand, NBOMe psychedelics like 25I-NBOMe are more efficacious at the serotonin 5-HT2A receptor and have been uniquely associated with serotonin syndrome-like toxicity.[41] In addition, serotonergic psychedelics additionally acting as serotonin releasing agents like methylenedioxyamphetamine (MDA) and α-methyltryptamine (AMT) or additionally acting as MAOIs like ayahuasca or AMT can cause serotonin syndrome.[44][41][15][6][45]

The relative risk and severity of serotonergic side effects and serotonin toxicity, with individual drugs and combinations, is complex. Serotonin syndrome has been reported in patients of all ages, including the elderly, children, and even newborn infants due to in utero exposure.[46][47][48][49] The serotonergic toxicity of SSRIs increases with dose, but even in overdose, it is insufficient to cause fatalities from serotonin syndrome in healthy adults.[50][51] Elevations of central nervous system (CNS) serotonin will typically only reach potentially fatal levels when drugs with different mechanisms of action are mixed together.[9] Various drugs, other than SSRIs, also have clinically significant potency as serotonin reuptake inhibitors, (such as tramadol, amphetamine, and MDMA) and are associated with severe cases of the syndrome.[6][52] Severe and life-threatening serotonin syndrome has been said to almost exclusively be due to a combination of antidepressants, for instance an MAOI with an SSRI.[44] However, combination of an MAOI and a serotonin releasing agent (SRA) like MDMA can also consistently result in severe and life-threatening serotonin syndrome.[40]

Although the most significant health risk associated with opioid overdoses is respiratory depression,[53] it is still possible for an individual to develop serotonin syndrome from certain opioids without the loss of consciousness. However, most cases of opioid-related serotonin syndrome involve the concurrent use of a serotergenic drug such as antidepressants.[54] Nonetheless, it is not uncommon for individuals taking opioids to also be taking antidepressants due to the comorbidity of pain and depression.[55] Cases where opioids alone are the cause of serotonin syndrome are typically seen with tramadol, because of its dual mechanism as a serotonin-norepinephrine reuptake inhibitor.[56][57] Serotonin syndrome caused by tramadol can be particularly problematic if an individual taking the drug is unaware of the risks associated with it and attempts to self-medicate symptoms such as headache, agitation, and tremors with more opioids, further exacerbating the condition.

## Pathophysiology

Serotonin is a neurotransmitter involved in multiple complex biological processes including aggression, pain, sleep, appetite, anxiety, depression, migraine, and vomiting.[10] In humans the effects of excess serotonin were first noted in 1960 in patients receiving an MAOI and tryptophan.[58] The syndrome is caused by increased serotonin in the CNS.[6] It was originally suspected that agonism of serotonin 5-HT1A receptors in central grey nuclei and the medulla oblongata was responsible for the development of the syndrome.[59] Further study has determined that overstimulation of primarily the serotonin 5-HT2A receptors appears to contribute substantially to the condition, while the serotonin 5-HT1A receptor seems to play little role.[44][59] However, the serotonin 5-HT1A receptor may still contribute through a pharmacodynamic interaction in which increased synaptic concentrations of a serotonin agonist saturate all receptor subtypes.[6] Additionally, noradrenergic CNS hyperactivity may play a role as CNS norepinephrine concentrations are increased in serotonin syndrome and levels appear to correlate with the clinical outcome. Other neurotransmitters may also play a role; NMDA receptor antagonists and γ-aminobutyric acid have been suggested as affecting the development of the syndrome.[6] Serotonin toxicity is more pronounced following supra-therapeutic doses and overdoses, and they merge in a continuum with the toxic effects of overdose.[50][60]

### Spectrum concept

A postulated "spectrum concept" of serotonin toxicity emphasises the role that progressively increasing serotonin levels play in mediating the clinical picture as side effects merge into toxicity. The dose-response relationship is the effect of progressive elevation of serotonin, either by raising the dose of one drug, or combining it with another serotonergic drug which may produce large elevations in serotonin levels.[61][62] Some experts prefer the terms serotonin toxicity or serotonin toxidrome, to more accurately reflect that it is a form of poisoning.[9][62]

## Diagnosis

There is no specific test for serotonin syndrome. Diagnosis is by symptom observation and investigation of the person's history.[6] Several criteria have been proposed. The first evaluated criteria were introduced in 1991 by Harvey Sternbach.[6][29][63] Researchers later developed the Hunter Toxicity Criteria Decision Rules, which have better sensitivity and specificity, 84% and 97%, respectively, when compared with the gold standard of diagnosis by a medical toxicologist.[6][10] As of 2007, Sternbach's criteria were still the most commonly used.[9]

The most important symptoms for diagnosing serotonin syndrome are tremor, extreme aggressiveness, akathisia, or clonus (spontaneous, inducible and ocular).[10] Physical examination of the patient should include assessment of deep tendon reflexes and muscle rigidity, the dryness of the mucosa of the mouth, the size and reactivity of the pupils, the intensity of bowel sounds, skin color, and the presence or absence of sweating.[6] The patient's history also plays an important role in diagnosis, investigations should include inquiries about the use of prescription and over-the-counter drugs, illicit substances, and dietary supplements, as all these agents have been implicated in the development of serotonin syndrome.[6] To fulfill the Hunter Criteria, a patient must have taken a serotonergic agent and meet one of the following conditions:[10]

* Spontaneous clonus, or
* Inducible clonus plus agitation or diaphoresis, or
* Ocular clonus plus agitation or diaphoresis, or
* Tremor plus hyperreflexia, or
* Hypertonism plus temperature > 38 °C (100 °F) plus ocular clonus or inducible clonus

### Differential diagnosis

Serotonin toxicity has a characteristic picture which is generally hard to confuse with other medical conditions, but in some situations it may go unrecognized because it may be mistaken for a viral illness, anxiety disorders, neurological disorder, anticholinergic poisoning, sympathomimetic toxicity, or worsening psychiatric condition.[6][9][64] The condition most often confused with serotonin syndrome is neuroleptic malignant syndrome (NMS).[65][66] The clinical features of neuroleptic malignant syndrome and serotonin syndrome share some features which can make differentiating them difficult.[67] In both conditions, autonomic dysfunction and altered mental status develop.[59] However, they are actually very different conditions with different underlying dysfunction (serotonin excess vs dopamine blockade). Both the time course and the clinical features of NMS differ significantly from those of serotonin toxicity.[10] Serotonin toxicity has a rapid onset after the administration of a serotonergic drug and responds to serotonin blockade such as drugs like chlorpromazine and cyproheptadine. Dopamine receptor blockade (NMS) has a slow onset, typically evolves over several days after administration of a neuroleptic drug, and responds to dopamine agonists such as bromocriptine.[6][59]

Differential diagnosis may become difficult in patients recently exposed to both serotonergic and neuroleptic drugs. Bradykinesia and extrapyramidal "lead pipe" rigidity are classically present in NMS, whereas serotonin syndrome causes hyperkinesia and clonus; these distinct symptoms can aid in differentiation.[22][68]

## Management

Management is based primarily on stopping the usage of the precipitating drugs, the administration of serotonin antagonists such as cyproheptadine (with a regimen of 12 mg for the initial dose followed by 2 mg every 2 hours until clinical, while some claim that a higher initial dose up to 32 mg has more benefit[69]),[70] and supportive care including the control of agitation, the control of autonomic instability, and the control of hyperthermia.[6][71][72] Additionally, those who ingest large doses of serotonergic agents may benefit from gastrointestinal decontamination with activated charcoal if it can be administered within an hour of overdose.[9] The intensity of therapy depends on the severity of symptoms. If the symptoms are mild, treatment may only consist of discontinuation of the offending medication or medications, offering supportive measures, giving benzodiazepines for myoclonus, and waiting for the symptoms to resolve. Moderate cases should have all thermal and cardiorespiratory abnormalities corrected and can benefit from serotonin antagonists. The serotonin antagonist cyproheptadine is the recommended initial therapy, although there have been no controlled trials demonstrating its efficacy for serotonin syndrome.[9][73][74] Despite the absence of controlled trials, there are a number of case reports detailing apparent improvement after people have been administered cyproheptadine.[9] Animal experiments also suggest a benefit from serotonin antagonists.[75] Cyproheptadine is only available as tablets and therefore can only be administered orally or via a nasogastric tube; it is unlikely to be effective in people administered activated charcoal and has limited use in severe cases.[9] Cyproheptadine can be stopped when the person is no longer experiencing symptoms and the half life of serotonergic medications already passed.[2]

Additional pharmacological treatment for severe case includes administering atypical antipsychotic drugs with serotonin antagonist activity such as olanzapine or asenapine.[6] Critically ill people should receive the above therapies as well as sedation or neuromuscular paralysis.[6] People who have autonomic instability such as low blood pressure require treatment with direct-acting sympathomimetics such as epinephrine, norepinephrine, or phenylephrine.[6] Conversely, hypertension or tachycardia can be treated with short-acting antihypertensive drugs such as nitroprusside or esmolol; longer acting drugs such as propranolol should be avoided as they may lead to hypotension and shock.[6] The cause of serotonin toxicity or accumulation is an important factor in determining the course of treatment. Serotonin is catabolized by monoamine oxidase A in the presence of oxygen, so if care is taken to prevent an unsafe spike in body temperature or metabolic acidosis, oxygenation will assist in dispatching the excess serotonin. The same principle applies to alcohol intoxication. In cases of serotonin syndrome caused by MAOIs, oxygenation will not help to dispatch serotonin. In such instances, hydration is the main concern until the enzyme is regenerated.

### Agitation

Specific treatment for some symptoms may be required. One of the most important treatments is the control of agitation due to the extreme possibility of injury to the person themselves or caregivers, benzodiazepines should be administered at first sign of this.[6] Physical restraints are not recommended for agitation or delirium as they may contribute to mortality by enforcing isometric muscle contractions that are associated with severe lactic acidosis and hyperthermia. If physical restraints are necessary for severe agitation they must be rapidly replaced with pharmacological sedation.[6] The agitation can cause a large amount of muscle breakdown. This breakdown can cause severe damage to the kidneys through a condition called rhabdomyolysis.[76]

### Hyperthermia

Treatment for hyperthermia includes reducing muscle overactivity via sedation with a benzodiazepine. More severe cases may require muscular paralysis with vecuronium, intubation, and artificial ventilation.[6][9] Suxamethonium is not recommended for muscular paralysis as it may increase the risk of cardiac dysrhythmia from hyperkalemia associated with rhabdomyolysis.[6] Antipyretic agents are not recommended as the increase in body temperature is due to muscular activity, not a hypothalamic temperature set point abnormality.[6]

## Prognosis

Upon the discontinuation of serotonergic drugs, most cases of serotonin syndrome resolve within 24 hours,[6][9][77][78] although in some cases delirium may persist for a number of days.[29] Symptoms typically persist for a longer time frame in patients taking drugs which have a long elimination half-life, active metabolites, or a protracted duration of action.[6]

Cases have reported persisting chronic symptoms,[79] and antidepressant discontinuation may contribute to ongoing features.[80] Following appropriate medical management, serotonin syndrome is generally associated with a favorable prognosis.[81]

## Epidemiology

Epidemiological studies of serotonin syndrome are difficult as many physicians are unaware of the diagnosis or they may miss the syndrome due to its variable manifestations.[6][82] In 1998 a survey conducted in England found that 85% of the general practitioners that had prescribed the antidepressant nefazodone were unaware of serotonin syndrome.[47] The incidence may be increasing as a larger number of pro-serotonergic drugs (drugs which increase serotonin levels) are now being used in clinical practice.[73] One postmarketing surveillance study identified an incidence of 0.4 cases per 1000 patient-months for patients who were taking nefazodone.[47] Additionally, around 14 to 16% of persons who overdose on SSRIs are thought to develop serotonin syndrome.[50]

## History

Serotonin syndrome, or serotonin toxicity, was first reported in humans in 1982.[44][83] It had previously been observed in animals.[44][83][84] However, serotonin syndrome-like toxicity had previously been reported as early as the 1960s, but these cases were not recognized as serotonin toxicity.[44] Serotonin syndrome was first defined as a distinct clinical entity and formally given the name "serotonin syndrome" in 1991.[44][85]

## Notable cases

Phenelzine is an MAOI which contributed to serotonin syndrome in the Libby Zion case.

The most widely recognized example of serotonin syndrome was the death of Libby Zion in 1984.[86] Zion was a freshman at Bennington College at her death on March 5, 1984, at age 18. She died within 8 hours of her emergency admission to the New York Hospital Cornell Medical Center. She had an ongoing history of depression, and came to the Manhattan hospital on the evening of March 4, 1984, with a fever, agitation and "strange jerking motions" of her body. She also seemed disoriented at times. The emergency room physicians were unable to diagnose her condition definitively but admitted her for hydration and observation. Her death was caused by a combination of pethidine and phenelzine.[87] A medical intern prescribed the pethidine.[88] The case influenced graduate medical education and residency work hours. Limits were set on working hours for medical postgraduates, commonly referred to as interns or residents, in hospital training programs, and they also now require closer senior physician supervision.[8]

## See also

* Carcinoid syndrome

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Ferri, Fred F. (2016) (in en). Ferri's Clinical Advisor 2017: 5 Books in 1. Elsevier Health Sciences. pp. 1154–1155. ISBN 978-0-323-44838-3. https://books.google.com/books?id=rRhCDAAAQBAJ&pg=PA1154.
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 "Serotonin syndrome". The Ochsner Journal 13 (4): 533–40. 2013. PMID 24358002.
3. ↑ 3.0 3.1 3.2 Domino, Frank J.; Baldor, Robert A. (2013) (in en). The 5-Minute Clinical Consult 2014. Lippincott Williams & Wilkins. p. 1124. ISBN 978-1-4511-8850-9. https://books.google.com/books?id=2C2MAwAAQBAJ&pg=PA1124.
4. ↑ New, Andrea M.; Nelson, Sarah; Leung, Jonathan G. (2015-10-01). Alexander, Earnest; Susla, Gregory M.. eds. "Psychiatric Emergencies in the Intensive Care Unit" (in en). AACN Advanced Critical Care 26 (4): 285–293. doi:10.4037/NCI.0000000000000104. ISSN 1559-7768. PMID 26484986. https://aacnjournals.org/aacnacconline/article/26/4/285/15256/Psychiatric-Emergencies-in-the-Intensive-Care-Unit.
5. ↑ Boyer EW , Shannon M . The serotonin syndrome . N Engl J Med. 2005 ; 352 ( 11 ): 1112-1120
6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19 6.20 6.21 6.22 6.23 6.24 6.25 6.26 6.27 6.28 6.29 6.30 6.31 6.32 6.33 6.34 6.35 6.36 6.37 6.38 6.39 6.40 6.41 6.42 6.43 6.44 6.45 6.46 6.47 6.48 6.49 6.50 6.51 6.52 6.53 6.54 6.55 6.56 6.57 "The serotonin syndrome". The New England Journal of Medicine 352 (11): 1112–1120. March 2005. doi:10.1056/NEJMra041867. PMID 15784664. http://toxicology.ucsd.edu/art 3 serotonin syndrome.pdf.
7. ↑ Friedman, Joseph H. (2015) (in en). Medication-Induced Movement Disorders. Cambridge University Press. p. 51. ISBN 978-1-107-06600-7. https://books.google.com/books?id=BqymCQAAQBAJ&pg=PA51.
8. ↑ 8.0 8.1 "Impact of the Libby Zion case on graduate medical education in internal medicine". The Mount Sinai Journal of Medicine, New York 65 (4): 296–300. September 1998. PMID 9757752.
9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 "Serotonin toxicity: a practical approach to diagnosis and treatment". Med J Aust 187 (6): 361–365. September 2007. doi:10.5694/j.1326-5377.2007.tb01282.x. PMID 17874986. http://www.mja.com.au/public/issues/187_06_170907/isb10375_fm.html.
10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 "The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity". QJM 96 (9): 635–642. September 2003. doi:10.1093/qjmed/hcg109. PMID 12925718.
11. ↑ 11.0 11.1 11.2 "Serotonin syndrome and other serotonergic disorders". Pain Medicine 4 (1): 63–74. March 2003. doi:10.1046/j.1526-4637.2003.03005.x. PMID 12873279.
12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 "Prescribing Practice Review 32: Managing depression in primary care". National Prescribing Service Limited. 2005. http://www.nps.org.au/__data/assets/pdf_file/0006/16971/ppr32.pdf.
13. ↑ "Serotonin syndrome triggered by a single dose of suboxone". American Journal of Emergency Medicine 26 (7): 840.e3–5. September 2008. doi:10.1016/j.ajem.2008.01.039. PMID 18774063.
14. ↑ 14.0 14.1 "The serotonin syndrome". New England Journal of Medicine 352 (23): 2454–2456. June 2005. doi:10.1056/NEJM200506093522320. PMID 15948273.
15. ↑ 15.0 15.1 ﻿Alpha-methyltryptamine (AMT) – Critical Review Report﻿ (Report). World Health Organisation – Expert Committee on Drug Dependence. 20 June 2014 (published 2014-06-20). https://legal-high-inhaltsstoffe.de/sites/default/files/uploads/amt.pdf. Retrieved 2019-11-18.
16. ↑ Taylor, Marygrace (2009-05-12). "Does the Caffeine in Your Coffee, Tea, or Soft Drinks Interfere With Antidepressants?". https://www.healthcentral.com/article/coffee-tea-not-good-maintaining-antidepressants-system.
17. ↑ "The clinical toxicology of metamfetamine". Clinical Toxicology 48 (7): 675–694. August 2010. doi:10.3109/15563650.2010.516752. PMID 20849327.
18. ↑ "Vyvanse (Lisdexamfetamine Dimesylate) Drug Information: Side Effects and Drug Interactions – Prescribing Information" (in en). RxList.com. http://www.rxlist.com/vyvanse-drug/side-effects-interactions.htm.
19. ↑ "Adderall (Amphetamine, Dextroamphetamine Mixed Salts) Drug Information: Side Effects and Drug Interactions – Prescribing Information" (in en). RxList. http://www.rxlist.com/adderall-drug/side-effects-interactions.htm.
20. ↑ "Evidence for the Biogenic Formation of Amphetamine Derivatives from Components of Nutmeg". Pharmacology 9 (5): 312–316. October 1973. doi:10.1159/000136402. PMID 4737998.
21. ↑ "Erowid Yohimbe Vaults: Notes on Yohimbine by William White, 1994". http://www.erowid.org/plants/yohimbe/yohimbe_info1.shtml.
22. ↑ 22.0 22.1 "Serotonin syndrome: a brief review". CMAJ 168 (11): 1439–42. May 2003. PMID 12771076. PMC 155963. http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=12771076.
23. ↑ "Mild serotonin syndrome associated with concurrent linezolid and fluoxetine". American Journal of Health-System Pharmacy 64 (1): 59–62. January 2007. doi:10.2146/ajhp060227. PMID 17189581.
24. ↑ "Combination risperidone and SSRI-induced serotonin syndrome". Annals of Pharmacotherapy 37 (3): 388–391. 2003. doi:10.1345/aph.1C228. PMID 12639169.
25. ↑ "Serotonin syndrome caused by olanzapine and clomipramine". Minerva Anestesiologica 74 (1–2): 41–45. 2008. PMID 18004234. http://www.minervamedica.it/index2.t?show=R02Y2008N01A0041.
26. ↑ "Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction". Br J Pharmacol 152 (6): 946–51. 2007. doi:10.1038/sj.bjp.0707430. PMID 17721552.
27. ↑ "Demystifying serotonin syndrome (or serotonin toxicity)". Canadian Family Physician 64 (10): 720–727. October 2018. PMID 30315014.
28. ↑ "Drug-induced serotonin syndrome: a review". Expert Opinion on Drug Safety 7 (5): 587–596. September 2008. doi:10.1517/14740338.7.5.587. PMID 18759711.
29. ↑ 29.0 29.1 29.2 Sternbach H (June 1991). "The serotonin syndrome". American Journal of Psychiatry 148 (6): 705–713. doi:10.1176/ajp.148.6.705. PMID 2035713.
30. ↑ Gillman, P. Ken (2006-06-01). "A Review of Serotonin Toxicity Data: Implications for the Mechanisms of Antidepressant Drug Action" (in en). Biological Psychiatry 59 (11): 1046–1051. doi:10.1016/j.biopsych.2005.11.016. ISSN 0006-3223. PMID 16460699. https://www.biologicalpsychiatryjournal.com/article/S0006-3223(05)01441-1/abstract.
31. ↑ "Olanzapine and serotonin toxicity". Psychiatry and Clinical Neurosciences 57 (2): 241–42. April 2003. doi:10.1046/j.1440-1819.2003.01110.x. PMID 12667176.
32. ↑ Gillman P (2006). "A systematic review of the serotonergic effects of mirtazapine in humans: implications for its dual action status". Human Psychopharmacology 21 (2): 117–125. doi:10.1002/hup.750. PMID 16342227.
33. ↑ Munhoz RP (2004). "Serotonin syndrome induced by a combination of bupropion and SSRIs". Clinical Neuropharmacology 27 (5): 219–222. doi:10.1097/01.wnf.0000142754.46045.8c. PMID 15602102.
34. ↑ "Bupropion induced serotonin syndrome: a case report". Journal of Medical Toxicology 6 (2): 168–171. June 2010. doi:10.1007/s13181-010-0021-x. PMID 20238197.
35. ↑ Gillman PK (June 2010). "Bupropion, bayesian logic and serotonin toxicity". Journal of Medical Toxicology 6 (2): 276–77. doi:10.1007/s13181-010-0084-8. PMID 20440594.
36. ↑ 36.0 36.1 Evans RW (2007). "The FDA alert on serotonin syndrome with combined use of SSRIs or SNRIs and Triptans: an analysis of the 29 case reports". MedGenMed 9 (3): 48. PMID 18092054.
37. ↑ "Serotonin syndrome risks when combining SSRI/SNRI drugs and triptans: is the FDA's alert warranted?". Annals of Pharmacotherapy 42 (11): 1692–1696. November 2008. doi:10.1345/aph.1L260. PMID 18957623.
38. ↑ "Serotonin syndrome and atypical antipsychotics". American Journal of Psychiatry 159 (4): 672–73. April 2002. doi:10.1176/appi.ajp.159.4.672-a. PMID 11925312.
39. ↑ Boyer and Shannon's reply to Gillman PK (June 2005). "The serotonin syndrome". New England Journal of Medicine 352 (23): 2454–2456. doi:10.1056/NEJM200506093522320. PMID 15948272.
40. ↑ 40.0 40.1 40.2 "Serotonin toxicity of serotonergic psychedelics". Psychopharmacology (Berl) 239 (6): 1881–1891. June 2022. doi:10.1007/s00213-021-05876-x. PMID 34251464.
41. ↑ 41.0 41.1 41.2 41.3 Cite error: Invalid `<ref>` tag; no text was provided for refs named `Thomas2024`
42. ↑ 42.0 42.1 42.2 "Concomitant use of antidepressants and classic psychedelics: A scoping review". J Psychopharmacol: 2698811251368360. September 2025. doi:10.1177/02698811251368360. PMID 40937732. "Importantly, the idea of increased risk for developing serotonin syndrome and/or serotonin toxicity, when [antidepressants (ADs)] are co-administered with high doses of psychedelics, has recently been challenged, in part because classic psychedelics are partial agonists of the 5-HT2A receptor and would also compete for serotonin binding (Malcolm and Thomas, 2022; Rickli et al., 2016; Sarparast et al., 2022). Based on this clinical rationale, the concomitant use of ADs and classic psychedelics may be preferred, or patients could temporarily reduce the dose of ADs around dosing days with psychedelics to have minimal interactions. Simultaneously, the competition for 5-HT2A receptors could impede the biological action of psychedelics during concomitant use of ADs and potentially limit efficacy (Halman et al., 2024), particularly as the 5-HT2A receptor induces neuroplasticity (Cameron et al., 2023; Ly et al., 2018; Vargas et al., 2023).".
43. ↑ "Does getting high hurt? Characterization of cases of LSD and psilocybin-containing mushroom exposures to national poison centers between 2000 and 2016". J Psychopharmacol 32 (12): 1286–1294. December 2018. doi:10.1177/0269881118793086. PMID 30182795.
44. ↑ 44.0 44.1 44.2 44.3 44.4 44.5 44.6 "The pathophysiology of serotonin toxicity in animals and humans: implications for diagnosis and treatment". Clin Neuropharmacol 28 (5): 205–214. 2005. doi:10.1097/01.wnf.0000177642.89888.85. PMID 16239759.
45. ↑ "New psychoactive substances (NPS) and serotonin syndrome onset: A systematic review". Exp Neurol 339. May 2021. doi:10.1016/j.expneurol.2021.113638. PMID 33571533.
46. ↑ "Effects of exposure to selective serotonin reuptake inhibitors during pregnancy on serotonergic symptoms in newborns and cord blood monoamine and prolactin concentrations". Archives of General Psychiatry 60 (7): 720–726. July 2003. doi:10.1001/archpsyc.60.7.720. PMID 12860776.
47. ↑ 47.0 47.1 47.2 "Antidepressants and the serotonin syndrome in general practice". Br J Gen Pract 49 (448): 871–4. November 1999. PMID 10818650.
48. ↑ "Neonatal paroxetine withdrawal syndrome or actually serotonin syndrome?". Archives of Disease in Childhood. Fetal and Neonatal Edition 85 (2): F147–48. September 2001. doi:10.1136/fn.85.2.F145g. PMID 11561552.
49. ↑ "Serotonin syndrome in a child after a single dose of fluvoxamine". Annals of Emergency Medicine 33 (4): 457–459. April 1999. doi:10.1016/S0196-0644(99)70313-6. PMID 10092727.
50. ↑ 50.0 50.1 50.2 "Relative toxicity of selective serotonin reuptake inhibitors (SSRIs) in overdose". J Toxicol Clin Toxicol 42 (3): 277–85. 2004. doi:10.1081/CLT-120037428. PMID 15362595.
51. ↑ "Redefining the serotonin syndrome [abstract]". Journal of Toxicology: Clinical Toxicology 40 (5): 668–69. 2002. doi:10.1081/CLT-120016866.
52. ↑ "Death following ingestion of MDMA (ecstasy) and moclobemide". Addiction 98 (3): 365–368. 2003. doi:10.1046/j.1360-0443.2003.00292.x. PMID 12603236.
53. ↑ "Management of opioid analgesic overdose". The New England Journal of Medicine 367 (2): 146–155. July 2012. doi:10.1056/NEJMra1202561. PMID 22784117.
54. ↑ Rickli, Anna et al. (2018). "Opioid-induced Inhibition of the Human 5-HT and Noradrenaline Transporters in Vitro: Link to Clinical Reports of Serotonin Syndrome". British Journal of Pharmacology 175 (3): 532–543. doi:10.1111/bph.14105. PMID 29210063.
55. ↑ "Depression and pain comorbidity: a literature review". Archives of Internal Medicine 163 (20): 2433–2445. November 2003. doi:10.1001/archinte.163.20.2433. PMID 14609780.
56. ↑ "Tramadol Hydrochloride". The American Society of Health-System Pharmacists. https://www.drugs.com/monograph/tramadol-hydrochloride.html.
57. ↑ "Serotonin Syndrome Associated With Tramadol". Primary Care Companion to the Journal of Clinical Psychiatry 11 (5): 273. 2009. doi:10.4088/PCC.08l00690. PMID 19956471.
58. ↑ "Neurologic effects of tryptophan in patients receiving a monoamine oxidase inhibitor". Neurology 10 (12): 1076–8. December 1960. doi:10.1212/WNL.10.12.1076. PMID 13730138.
59. ↑ 59.0 59.1 59.2 59.3 Whyte, Ian M. (2004). "Serotonin Toxicity/Syndrome". Medical Toxicology. Philadelphia: Williams & Wilkins. pp. 103–6. ISBN 978-0-7817-2845-4.
60. ↑ "Relative toxicity of venlafaxine and selective serotonin reuptake inhibitors in overdose compared to tricyclic antidepressants". QJM 96 (5): 369–74. 2003. doi:10.1093/qjmed/hcg062. PMID 12702786.
61. ↑ Gillman PK (June 2004). "The spectrum concept of serotonin toxicity". Pain Med 5 (2): 231–2. doi:10.1111/j.1526-4637.2004.04033.x. PMID 15209988.
62. ↑ 62.0 62.1 Gillman PK (June 2006). "A review of serotonin toxicity data: implications for the mechanisms of antidepressant drug action". Biol Psychiatry 59 (11): 1046–51. doi:10.1016/j.biopsych.2005.11.016. PMID 16460699.
63. ↑ "The serotonin syndrome scale: first results on validity". Eur Arch Psychiatry Clin Neurosci 248 (2): 96–103. 1998. doi:10.1007/s004060050024. PMID 9684919. http://link.springer.de/link/service/journals/00406/bibs/8248002/82480096.htm.
64. ↑ "Serotonin syndrome: case report and current concepts". Ir Med J 98 (5): 143–4. 2005. PMID 16010782.
65. ↑ "Neuroleptic malignant syndrome and serotonin syndrome". Neurobiology of Hyperthermia. Progress in Brain Research. 162. 2007. 81–104. doi:10.1016/S0079-6123(06)62006-2. ISBN 978-0-444-51926-9.
66. ↑ Tormoehlen, LM; Rusyniak, DE (2018). "Neuroleptic malignant syndrome and serotonin syndrome". Thermoregulation: From Basic Neuroscience to Clinical Neurology, Part II. Handbook of Clinical Neurology. 157. pp. 663–675. doi:10.1016/B978-0-444-64074-1.00039-2. ISBN 978-0-444-64074-1.
67. ↑ "[Malignant neuroleptic syndrome or serotonergic syndrome]". Ugeskrift for Læger 163 (3): 301–2. 2001. PMID 11219110.
68. ↑ "Citalopram overdose, serotonin toxicity, or neuroleptic malignant syndrome?". Can J Psychiatry 46 (7): 657–9. September 2001. doi:10.1177/070674370104600718. PMID 11582830.
69. ↑ Prakash, Sanjay; Shah, Chetsi S.; Prakash, Anurag (2024-06-09). "Serotonin syndrome controversies: A need for consensus". World Journal of Critical Care Medicine 13 (2). doi:10.5492/wjccm.v13.i2.94707. ISSN 2220-3141. PMID 38855279.
70. ↑ Scotton, William J; Hill, Lisa J; Williams, Adrian C; Barnes, Nicholas M (2019). "Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions". International Journal of Tryptophan Research (SAGE Publications) 12: 117864691987392. doi:10.1177/1178646919873925. ISSN 1178-6469. PMID 31523132.
71. ↑ Sporer K (1995). "The serotonin syndrome. Implicated drugs, pathophysiology and management". Drug Saf 13 (2): 94–104. doi:10.2165/00002018-199513020-00004. PMID 7576268.
72. ↑ Frank, Christopher (2008). "Recognition and treatment of serotonin syndrome". Can Fam Physician 54 (7): 988–92. PMID 18625822.
73. ↑ 73.0 73.1 "Treatment of the serotonin syndrome with cyproheptadine". J Emerg Med 16 (4): 615–9. 1998. doi:10.1016/S0736-4679(98)00057-2. PMID 9696181.
74. ↑ Gillman PK (1999). "The serotonin syndrome and its treatment". J Psychopharmacol (Oxford) 13 (1): 100–9. doi:10.1177/026988119901300111. PMID 10221364. https://zenodo.org/record/844143.
75. ↑ "Potent serotonin (5-HT)(2A) receptor antagonists completely prevent the development of hyperthermia in an animal model of the 5-HT syndrome". Brain Res. 890 (1): 23–31. January 2001. doi:10.1016/S0006-8993(00)03020-1. PMID 11164765.
76. ↑ "Serotonin syndrome – PubMed Health". Ncbi.nlm.nih.gov. 8 July 2012. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004531/.
77. ↑ Prator B (2006). "Serotonin syndrome". J Neurosci Nurs 38 (2): 102–5. doi:10.1097/01376517-200604000-00005. PMID 16681290.
78. ↑ "[Serotonin syndrome. Which treatment and when?]". Presse Med 30 (34): 1695–700. 2001. PMID 11760601.
79. ↑ Chechani V (February 2002). "Serotonin syndrome presenting as hypotonic coma and apnea: potentially fatal complications of selective serotonin receptor inhibitor therapy". Crit Care Med 30 (2): 473–6. doi:10.1097/00003246-200202000-00033. PMID 11889332.
80. ↑ Haddad PM (2001). "Antidepressant discontinuation syndromes". Drug Saf 24 (3): 183–97. doi:10.2165/00002018-200124030-00003. PMID 11347722.
81. ↑ "Serotonin syndrome. Presentation of 2 cases and review of the literature". Medicine (Baltimore) 79 (4): 201–9. July 2000. doi:10.1097/00005792-200007000-00001. PMID 10941349.
82. ↑ "Serotonin syndrome: potentially fatal but difficult to recognize". Br J Gen Pract 49 (448): 867–8. November 1999. PMID 10818648.
83. ↑ 83.0 83.1 "Possible development of the serotonin syndrome in man". Am J Psychiatry 139 (7): 954–955. July 1982. doi:10.1176/ajp.139.7.954. PMID 7091416.
84. ↑ "An animal behavior model for studying central serotonergic synapses". Life Sci 19 (6): 777–785. September 1976. doi:10.1016/0024-3205(76)90303-9. PMID 823389.
85. ↑ "The serotonin syndrome". Am J Psychiatry 148 (6): 705–713. June 1991. doi:10.1176/ajp.148.6.705. PMID 2035713.
86. ↑ Brody, Jane (February 27, 2007). "A Mix of Medicines That Can Be Lethal". New York Times. https://www.nytimes.com/2007/02/27/health/27brody.html?n=Top/News/Health/Diseases, Conditions, and Health Topics/Antidepressants.
87. ↑ "The Libby Zion case. One step forward or two steps backward?". N Engl J Med 318 (12): 771–5. March 1988. doi:10.1056/NEJM198803243181209. PMID 3347226.
88. ↑ Jan Hoffman (January 1, 1995). "Doctors' Accounts Vary In Death of Libby Zion". The New York Times. https://query.nytimes.com/gst/fullpage.html?sec=health&res=990CE4DC1230F932A35752C0A963958260.

## External links

* Image demonstrating findings in moderately severe serotonin syndrome from "The serotonin syndrome". N Engl J Med 352 (11): 1112–20. 2005. doi:10.1056/NEJMra041867. PMID 15784664.

Classification|

* ICD-11: 8D85
* ICD-9-CM: 333.99
* DiseasesDB: 30044

|

External resources|

* MedlinePlus: 007272
* eMedicine: ped/2786

* v
* t
* e

Diseases of the nervous system, primarily CNS (G04–G47, 323–349)

Inflammation|

| Brain|

* Encephalitis
* Viral encephalitis
* Herpesviral encephalitis
* Limbic encephalitis
* Encephalitis lethargica
* Cavernous sinus thrombosis
* Brain abscess
* Amoebic

|

Spinal cord|

* Myelitis: Poliomyelitis
* Demyelinating disease
* Transverse myelitis
* Tropical spastic paraparesis
* Epidural abscess

Both/either|

* Encephalomyelitis
* Acute disseminated
* Myalgic
* Meningoencephalitis

Brain/
encephalopathy|

| Degenerative|

| Extrapyramidal and
movement disorders|

* Basal ganglia disease
* Parkinsonism
* PD
* Postencephalitic
* NMS
* PKAN
* Tauopathy
* PSP
* Striatonigral degeneration
* Hemiballismus
* HD
* OA

* Dyskinesia
* Dystonia
* Status dystonicus
* Spasmodic torticollis
* Meige's
* Blepharospasm
* Athetosis
* Chorea
* Choreoathetosis
* Myoclonus
* Myoclonic epilepsy
* Akathisia

* Tremor
* Essential tremor
* Intention tremor
* Restless legs
* Stiff-person

|

Dementia|

* Tauopathy
* Alzheimer's
* Early-onset
* Primary progressive aphasia
* Frontotemporal dementia/Frontotemporal lobar degeneration
* Pick's
* Dementia with Lewy bodies
* Posterior cortical atrophy

* Vascular dementia

Mitochondrial disease|

* Leigh syndrome

Demyelinating|

* autoimmune
* Multiple sclerosis
* Neuromyelitis optica
* Schilder's disease
* hereditary
* Adrenoleukodystrophy
* Alexander
* Canavan
* Krabbe
* ML
* PMD
* VWM
* MFC
* CAMFAK syndrome
* Central pontine myelinolysis
* Marchiafava–Bignami disease
* Alpers' disease

Episodic/
paroxysmal|

| Seizure/epilepsy|

* Focal
* Generalised
* Status epilepticus
* Myoclonic epilepsy

|

Headache|

* Migraine
* Familial hemiplegic
* Cluster
* Tension

Cerebrovascular|

* TIA
* Amaurosis fugax
* Transient global amnesia
* Acute aphasia

* Stroke
* MCA
* ACA
* PCA
* Foville's
* Millard–Gubler
* Lateral medullary
* Medial medullary
* Weber's
* Lacunar stroke

Sleep disorders|

* Insomnia
* Hypersomnia
* Sleep apnea
* Obstructive
* Congenital central hypoventilation syndrome
* Narcolepsy
* Cataplexy
* Kleine–Levin
* Circadian rhythm sleep disorder
* Advanced sleep phase disorder
* Delayed sleep phase disorder
* Non-24-hour sleep–wake disorder
* Jet lag

CSF|

* Intracranial hypertension
* Hydrocephalus/NPH
* Choroid plexus papilloma
* Idiopathic intracranial hypertension
* Cerebral edema
* Intracranial hypotension

Other|

* Brain herniation
* Reye's
* Hepatic encephalopathy
* Toxic encephalopathy
* Hashimoto's encephalopathy

Spinal cord/
myelopathy|

* Syringomyelia
* Syringobulbia
* Morvan's syndrome
* Vascular myelopathy
* Foix–Alajouanine syndrome
* Spinal cord compression

Both/either|

| Degenerative|

| SA|

* Friedreich's ataxia
* Ataxia–telangiectasia

|

MND|

* UMN only:
* Primary lateral sclerosis
* Pseudobulbar palsy
* Hereditary spastic paraplegia

* LMN only:
* Distal hereditary motor neuronopathies
* Spinal muscular atrophies
* SMA
* SMAX1
* SMAX2
* DSMA1
* Congenital DSMA
* SMA-PCH
* SMA-LED
* SMA-PME
* Progressive muscular atrophy
* Progressive bulbar palsy
* Fazio–Londe
* Infantile progressive bulbar palsy

* both:
* Amyotrophic lateral sclerosis

* v
* t
* e

* Poisoning
* Toxicity
* Overdose (T36–T65, 960–989)

History of poison

Inorganic|

| Metals|

| Toxic metals|

* Beryllium
* Cadmium
* Lead
* Mercury
* Nickel
* Silver
* Thallium
* Tin

|

Dietary minerals|

* Chromium
* Cobalt
* Copper
* Iron
* Manganese
* Zinc

Metalloids|

* Arsenic

Nonmetals|

* Sulfuric acid
* Selenium
* Chlorine
* Fluoride

Organic|

| Phosphorus|

* Pesticides
* Aluminium phosphide
* Organophosphates

|

Nitrogen|

* Cyanide
* Nicotine
* Nitrogen dioxide poisoning

CHO|

* alcohol
* Ethanol
* Ethylene glycol
* Methanol
* Carbon monoxide
* Oxygen
* Toluene

Pharmaceutical|

| Drug overdoses|

| Nervous|

* Anticholinesterase
* Aspirin
* Barbiturates
* Benzodiazepines
* Cocaine
* Lithium
* Opioids
* Paracetamol
* Tricyclic antidepressants

|

Cardiovascular|

* Digoxin
* Dipyridamole

Vitamin poisoning|

* Vitamin A
* Vitamin D
* Vitamin E
* Megavitamin-B6 syndrome

Biological1|

| Fish / seafood|

* Ciguatera
* Haff disease
* Ichthyoallyeinotoxism
* Scombroid
* Shellfish poisoning
* Amnesic
* Diarrhetic
* Neurotoxic
* Paralytic

|

Other vertebrates|

* amphibian venom
* Batrachotoxin
* Bombesin
* Bufotenin
* Physalaemin
* birds / quail
* Coturnism
* snake venom
* Alpha-Bungarotoxin
* Ancrod
* Batroxobin

Arthropods|

* Arthropod bites and stings
* bee sting / bee venom
* Apamin
* Melittin
* scorpion venom
* Charybdotoxin
* spider venom
* Latrotoxin / Latrodectism
* Loxoscelism
* tick paralysis

Plants / fungi|

* Cinchonism
* Ergotism
* Lathyrism
* Locoism
* Mushrooms
* Strychnine

1 including venoms, toxins, foodborne illnesses.

0.00

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