New Blog

Hello blog readers-
If you have this as "The Story of Donn" and are wondering why we haven't updated since the beginning of May, there's a reason.
I have a new website. Please go to:

www.katie.schnolis.com/storyofdonn.

Thanks!

Pardon me, do you have any Grey Poopon(tine)?

But of course

check the name on his bracelet

You talk about Poopontine and Underwear (pants, whatever).....and to think of all the years you have been calling me Ain't "B"

So glad to hear there is a bit of progress with Donnell.

I'm a prayin'

Love Ain't "B"

Even though it's raining outside...

My dad's doing better inside ICU. His latest x-rays showed that he doesn't have ARDS right now. His infection is only at the bottom of his lungs. The dialysis went well and he doesn't need as much oxygen. Yay!

My Name is Tine....Poopontine

Come on back Dad

Fun With Trains

Thursday Night

Hello Everyone-

I just got back from the hospital and here's the newest update. I'd like to expand my vocabulary. I've said update so many times that it's losing its meaning... Ok, I spent 30 seconds trying and www.thesaurus.com offers no help. Anyway. Here's the latest.

My dad started dialysis around 7:00 pm. It seemed to be going well. At one point there was a blood clot in one of the lines, but the tech told my uncle Dave that it was not a problem. He would just have to run the machine for an extra 20 minutes or so. After Danny and I left the ICU waiting room where we had been sitting with Dave, my mom, Amy and my uncle John, Dave went back into my dad's room. So I'm not sure if anything has come about since we left.

We were told that my dad still has pneumonia, and if it progresses any farther, he will have what is known as ARDS: Acute Respiratory Distress Syndrome. It is being treated with antibiotics, but Amy said that my dad's doctor said that right now, my dad does not have ARDS. He'll be able to see the newest results with an x-ray tomorrow.
Webmd, what do you have to tell us about ARDS?

Acute respiratory distress syndrome (ARDS) is a type of severe, acute lung dysfunction affecting all or most of both lungs that occurs as a result of illness or injury. Although it is sometimes called adult respiratory distress syndrome, it may also affect children. Major symptoms may include breathing difficulties (dyspnea), rapid breathing (tachypnea), excessively deep and rapid breathing (hyperventilation) and insufficient levels of oxygen in the circulating blood (hypoxemia). ARDS may develop in conjunction with widespread infection in the body (sepsis) or as a result of pneumonia, trauma, shock, severe burns, aspiration of food into the lung, multiple blood transfusions, and inhalation of toxic fumes, among other things. It usually develops within 24 to 48 hours after the original illness or injury and is considered a medical emergency. It may progress to involvement of other organs.

Treatment for ARDS from pulmonologychannel.com


Treatment for ARDS from www.ards.org

There are no currently established medication treatments for combating ARDS itself. Use of steroids, whether through inhalation therapy or otherwise, has been advocated and studied. Certain studies have ruled out various other medication treatments as being ineffective. Some studies are underway to determine the efficacy of other medication therapies. Most medication treatments are oriented toward the underlying medical problems which the patient is battling, such as sepsis and trauma. In addition, other common medications which may be employed during the battle with ARDS include sedating drugs, paralyzing drugs, anti-anxiety medication, and antibiotics to combat or stave off infections. These medications do not directly battle ARDS in a medical sense, rather they are supportive in the battle against ARDS to allow the lungs to heal in hopefully the best medical and physical situation possible considering the underlying medical problems and the severity of the ARDS.

My dad is already on a respirator and on sedating and paralyzing drugs because of the breathing tube they're using to help his COPD and emphysema. They're also treating him with antibiotics.

Amy just sent me a text message saying that they're moving my dad to another room in the same ICU where he'll get a 1 on 1 patient to nurse ratio. She said that his blood pressure was low and they needed a nurse to monitor him constantly. She didn't give any other reasons for the move, and since they're doing it right now, I don't think they'll get one for awhile.



Also: we've been hearing that my dad probably has Seratonin Syndrome, as opposed to Neuroleptic Malignant Syndrome. Seriously, we're not sure. But here's some Seratonin Syndrome info from the Mayo Clinic. I've been trouble finding good information about it.



Original Article:

---

Serotonin syndrome

Introduction

Serotonin syndrome is a condition characterized by dangerously high levels of serotonin — a chemical produced by nerve cells — in your body.

Serotonin syndrome can occur when you take certain combinations of prescription medications that affect serotonin levels in your body. For example, serotonin syndrome can occur if you take selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) for depression along with triptan medications to treat migraine. Serotonin syndrome can also occur if you take SSRIs with other drugs or supplements that affect serotonin levels, such as St. John's wort.

Signs and symptoms of serotonin syndrome range from restlessness and rapid heartbeat to muscle rigidity and seizures. These go away quickly with treatment, which may include discontinuing use of the medications causing the symptoms along with taking other drugs such as muscle relaxants and serotonin-production blocking agents. If not treated quickly, serotonin syndrome can become life-threatening.

Signs and symptoms

Signs and symptoms of serotonin syndrome typically occur within several hours of taking a new drug or taking a previously used drug at an increased dosage level, and may include:

• Extreme agitation or restlessness
• Confusion
• Hallucinations
• Loss of coordination
• Fast heartbeat
• Rapid changes in blood pressure
• Fever
• Heavy sweating
• Overactive reflexes
• Nausea, vomiting and diarrhea
• Seizures
• Coma

Causes

Your nerve cells produce serotonin as a normal part of their functioning. Nerve cells in your brain and spinal cord (central nervous system) produce serotonin that helps regulate your attention, behavior and body temperature. Other nerve cells in your body, primarily in your intestines, also produce serotonin. In these other areas, serotonin plays a role in regulating your digestive process, blood flow and breathing.

When your body has too much serotonin, typically from taking too much medication that affects serotonin levels, the excess can cause serotonin syndrome.

Serotonin syndrome generally occurs when you take multiple drugs that affect serotonin levels in your body. In particular, taking an selective serotonin reuptake inhibitor (SSRI) along with triptans, a class of migraine medications, may cause the condition — potentially raising serotonin to dangerous levels.

However, serotonin syndrome can also occur when you start a single new drug that affects serotonin levels or when you take an increased dose of such a drug that you've previously used. Many drugs may lead to serotonin syndrome. These drugs include but aren't limited to:

• SSRIs such as citalopram (Celexa), fluoxetine (Prozac, Sarafem), fluvoxamine, paroxetine (Paxil) and sertraline (Zoloft)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as trazodone (Desyrel) and venlafaxine (Effexor)
• The norepinephrine and dopamine reuptake inhibitor (NDRI) buproprion (Wellbutrin, Zyban)
• Monoamine oxidase inhibitors (MAOIs) such as isocarboxazid (Marplan) and phenelzine (Nardil)
• Pain medications such as fentanyl (Sublimaze), meperidine (Demerol), pentazocine
  (Talwin) and tramadol (Ultram)
• Anti-nausea medications such as granisetron (Kytril), metoclopramide (Reglan) and ondansetron (Zofran)
• Anti-migraine medications such as almotriptan (Axert), naratriptan (Amerge), sumatriptan (Imitrex) and zolmitriptan (Zomig)
• Over-the-counter cough and cold medications containing dextromethorphan (Robitussin DM, Sudal DM)
• Illegal drugs such as Ecstasy, LSD and Syrian rue
• Herbal supplements such as St. John's wort and ginseng
• Lithium (Eskalith, Lithobid)

Screening and diagnosis

No single test can confirm a serotonin syndrome diagnosis. Your doctor will diagnose the condition by ruling out other possibilities.

Your doctor will likely start by asking about your medical history and any medications you're taking. Serotonin syndrome can mimic other conditions: for example, neuroleptic malignant syndrome — a condition that can occur following use of certain tranquilizer (neuroleptic) drugs — or an overdose of cocaine or an MAOI.

To rule out other conditions, your doctor may use tests that measure any other drugs you're using or abusing, check your hormone levels, and assess key body functions that may be affected by serotonin syndrome.

To be diagnosed with serotonin syndrome, you must be taking a drug that can affect your body's serotonin levels and be experiencing three of the following:

• Agitation
• Uncoordinated movements
• Heavy sweating not due to activity
• Diarrhea
• Overactive reflexes
• Fever
• Mental status changes such as confusion
• Muscle spasms
• Shivering
• Tremor

Treatment

Serotonin syndrome is treated by stopping any medications you're taking that could be increasing your serotonin levels. Your doctor also may keep you in the hospital for observation for several hours. Serotonin syndrome often resolves within 24 hours of stopping any medication that increases serotonin and starting any necessary treatment.

More severe cases of serotonin syndrome may require additional medications and longer hospitalization. Depending on your symptoms, you may receive the following treatments:

• Monitoring your vital signs, such as heart rate, blood pressure and temperature, and treating those as needed.
• Muscle relaxants. Benzodiazepines, such as diazepam (Valium) or lorazepam (Ativan), can help control agitation, seizure-like movements and muscle stiffness.
• Serotonin-production blocking agents. If other treatments aren't working, the drug cyproheptadine can help by blocking serotonin production.
• Drugs that control heart rate and blood pressure. These could include esmolol (Brevibloc) or nitroprusside (Nitropress) to reduce an increased heart rate or high blood pressure, or phenylephrine (Neo-Synephrine) or epinephrine to increase blood pressure that's too low.

If your condition is severe, you may also need a breathing tube and machine and medications that keep your muscles still (paralyze them).

Prevention

If you're taking serotonin-related drugs, particularly more than one, such as a triptan, with either an SSRI or SNRI, you may be at increased risk of serotonin syndrome. Talk to your doctor about possible risks. Don't stop taking any such medications on your own. If your doctor prescribes a new medication, make sure he or she knows about all the other medications you're taking — especially if you receive prescriptions from more than one doctor.

If you and your doctor decide the benefits of combining certain serotonin-level-affecting drugs outweigh the risks, be alert to the possibility of serotonin syndrome. If you develop restlessness, hallucinations or any other signs or symptoms of serotonin syndrome, seek medical attention immediately.

---

By Mayo Clinic Staff
Jun 22, 2007

Thursday Evening Update

Thanks, Sheila. I was trying not to focus on that, but, you know, information is important.

Ok, so my dad is now being hooked up to all of that fun kidney dialysis stuff as we speak. Well, as I type, but you get the idea. His urine output was too low, so they had to go this route. Amy is at the hospital now and she said that it takes 4 hours and they will keep my dad sedated, and give him some pain medication to make him feel comfortable. That's all I have for now.

TABERNACLE!!!!!!

"...almost 30% of people with this syndrome die"

This seems unusually high! Merde!

WebMD's NMS Info

Neuroleptic Malignant Syndrome

Synonyms:
· Drug-Induced Movement Disorder
· Neuroleptic-Induced Acute Dystonia
· Hyperthermia

General Discussion
Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to the use of almost any of a group of antipsychotic drugs or major tranquilizers (neuroleptics). These drugs are commonly prescribed for the treatment of schizophrenia and other neurological, mental, or emotional disorders. Several of the more commonly prescribed neuroleptics include thioridazine, haloperidol, chlorpromazine, fluphenazine and perphenazine.The syndrome is characterized by high fever, stiffness of the muscles, altered mental status (paranoid behavior), and autonomic dysfunction. Autonomic dysfunction alludes to defective operations of the components of the involuntary (autonomic) nervous system, leading to wide swings of blood pressure, excessive sweating and excessive secretion of saliva.A genetic basis for the disorder is suspected but not proven. It does appear to be clear that a defect in the receptors to dopamine (dopamine D2 receptor antagonism) is an important contributor to the cause of neuroleptic malignant syndrome.

Resources
Malignant Hyperthermia Association of the United States (MHAUS)
11 East State Street
PO Box 1069
Sherburne, NY 13460-1069
Tel: 6076747901
Fax: 6076747910
Email: info@mhaus.org
Internet: http://www.mhaus.org

North American Malignant Hyperthermia Registry of MHAUS
Children's Hospital of PittsburghRoom #74463705
Fifth Ave at DeSoto St
Pittsburgh, PA 15213-2583
Tel: 4126926390
Fax: 4126928658
Tel: 8882747899
Email: bwb+@pitt.eduI
Internet: http://www.mhreg.org

National Mental Health Consumers' Self-Help Clearinghouse
1211 Chestnut StreetSuite 1207
Philadelphia, PA 19107-6312 USA
Tel: 2127511810
Fax: 2156366312
Tel: 8005534539
Email: info@mhselfhelp.org
Internet: http://www.mhselfhelp.org

National Mental Health Association
2001 North Beauregard Street12th Floor
Alexandria, VA 22311 USA
Tel: 7036847722
Fax: 7036845968
Tel: 8009696642
TDD: 8004335959
Email: infoctr@nmha.org
Internet: http://www.nmha.org

National Alliance for the Mentally Ill
Colonial Place Three2107 Wilson Blvd.Suite 300
Arlington, VA 22201-3042 USA
Tel: 7035247600
Fax: 7035249094
Tel: 8009996264
TDD: 7035167227
Email: membership@nami.org
Internet: http://www.nami.orgNIH/

National Institute of Mental Health
6001 Executive BlvdRm 8184, MSC 9663
Rockville, MD 20892-9663
Tel: (301)443-4513
Email: nimhinfo@nih.gov
Internet: http://www.nimh.nih.gov/

Medic Alert Foundation International
2323 Colorado Avenue
Turlock, CA 95382 USA
Tel: 2096692401
Fax: 2096692456
Tel: 8004325378
Email: Inquiries@medicalert.org
Internet: http://www.medicalert.org

What is Neuroleptic Malignant Syndrome?

From the Merck Manual Website

[The website talks about Schizophrenia, but my dad doesn't have that. Somehow it's tied into the NMS, but I'm not sure yet how. I'll try to find out more about it.]

What Is Neuroleptic Malignant Syndrome?

Neuroleptic malignant syndrome is a state of unresponsiveness caused by use of certain antipsychotic drugs. It develops in up to 3% of people who are treated with antipsychotic drugs, usually within the first few weeks of treatment. The syndrome is most common among men who, because they are agitated, are given rapidly increased doses of the drugs or high doses initially.
Symptoms include muscle rigidity, a high temperature, a fast heart rate, a fast breathing rate, high blood pressure, and coma. Damaged muscles release the protein myoglobin, which is excreted in the urine. Myoglobin turns the urine brown (myoglobinuria), and myoglobinuria can result in kidney damage or even kidney failure.
People with this syndrome are usually treated in an intensive care unit. The antipsychotic drug is discontinued, fever is controlled (usually with ice baths and wet towels or with special cooling blankets), and a muscle relaxant (such as bromocriptineSome Trade Names PARLODELor dantroleneSome Trade Names DANTRIUM) is given. Giving sodium bicarbonate intravenously helps prevent myoglobulinuria by making the urine alkaline. Most people recover completely; however, almost 30% of people with this syndrome die. After recovery, up to 30% of people develop the syndrome again if they are given the same antipsychotic drug.

Treatment

The general goals of treatment are to reduce the severity of psychotic symptoms, prevent the recurrence of symptomatic episodes and the associated deterioration in functioning, and provide support to allow functioning at the highest level possible. Antipsychotic drugs, rehabilitation and community support activities, and psychotherapy represent the three major components of treatment.


Antipsychotic Drugs: Drugs can be effective in reducing or eliminating symptoms, such as delusions, hallucinations, and disorganized thinking. After the immediate symptoms have cleared, the continued use of antipsychotic drugs substantially reduces the probability of future episodes.

Unfortunately, antipsychotic drugs have significant side effects that can include sedation, muscle stiffness, tremors, weight gain, and motor restlessness. Antipsychotic drugs may also cause tardive dyskinesia, an involuntary movement disorder most often characterized by puckering of the lips and tongue or writhing of the arms or legs. Tardive dyskinesia may not go away even after the drug is discontinued. For tardive dyskinesia that persists, there is no effective treatment. Another side effect of antipsychotic drugs, although rare but potentially fatal, is neuroleptic malignant syndrome, which is characterized by muscle rigidity, fever, high blood pressure, and changes in mental function (for example, confusion and lethargy).
A number of new antipsychotic drugs that cause fewer side effects have become available. These drugs may relieve positive symptoms (such as hallucinations), negative symptoms (such as lack of emotion), and cognitive impairment (such as reduced mental functioning and attention span) to a greater extent than the older antipsychotic drugs.

ClozapineSome Trade Names CLOZARILhas proven to be effective in up to half of the people for whom other drugs do not work. However, clozapineSome Trade Names CLOZARILcan cause serious side effects, such as seizures or potentially fatal bone marrow suppression; thus, it is generally used only for people who have not responded to other antipsychotic drugs. People who take clozapineSome Trade Names CLOZARILmust have their white blood cell count measured weekly, at least for the first 6 months, so that clozapineSome Trade Names CLOZARILcan be discontinued at the first indication that the number of white blood cells is dropping.

Rehabilitation and Community Support Activities:

Community support activities, such as on-the-job coaching, are directed at teaching the skills needed to survive in the community. These skills enable a person with schizophrenia to work, shop, care for himself, manage a household, and get along with others. Although hospitalization may be needed during severe relapses, and involuntary hospitalization may be needed if the person poses a danger to himself or others, the general goal is to have the person live in the community. To achieve this goal, some people may need to live in a supervised apartment or group home where someone can ensure that drugs are taken as prescribed.

A small number of people with schizophrenia are unable to live independently, either because they have severe and unresponsive symptoms or because they lack the skills necessary to live in the community. They usually require full-time care in a safe and supportive setting.
Psychotherapy: Generally, the goal of psychotherapy is to establish a collaborative relationship between the person, family, and doctor. That way the person might learn to understand and manage his disorder, to take antipsychotic drugs as prescribed, and to manage stresses that can aggravate the disorder. A good doctor-patient relationship is often a major determinant of successful treatment. Psychotherapy reduces symptoms in some cases and helps prevent relapse in others.

Antipsychotic Drugs
Type
Drug
Selected Side Effects
Comments
Older antipsychotics

· Chlorpromazine
· Fluphenazine
· Haloperidol
· Loxapine
· Mesoridazine
· Molindone
· Perphenazine
· Pimozide
· Thioridazine
· Thiothixene
· Trifluoperazine
Dry mouth, blurred vision, seizures, increased heart rate, decreased blood pressure, constipation, sudden but often reversible tremor and muscle stiffness that may progress to rigidity, uncontrolled movements of the face and arms (tardive dyskinesia), fever and muscle damage (neuroleptic malignant syndrome)
Side effects are much more likely in older people and in people with impaired balance or serious medical disorders. Long-acting injectable forms of haloperidolSome Trade Names HALDOLand perphenazineSome Trade Names TRILAFONare available
Eye examination and electrocardiography (ECG) are recommended while taking thioridazineSome Trade Names MELLARIL
Newer antipsychotics

· Aripiprazole
· Clozapine
· Olanzapine
· Quetiapine
· Risperidone
· Ziprasidone
Drowsiness and weight gain, which can be substantial, are the most common side effects. May increase the risk of new-onset type II diabetes and high levels of triglycerides in the blood. Muscle tremor, uncontrolled movements of the face and arms (tardive dyskinesia), and muscle damage possible but occur less often compared to older antipsychotics.
Newer antipsychotics are less likely to cause tremor, muscle stiffness, uncontrolled movements, and fever and muscle damage
ClozapineSome Trade Names CLOZARILis used much less often because it can cause bone marrow suppression, reduced white blood cell count, and seizures. However, it is often effective in people who are not responsive to other drugs
ClozapineSome Trade Names CLOZARILand olanzapineSome Trade Names ZYPREXAare most likely to cause weight gain; aripiprazole is the least likely
ZiprasidoneSome Trade Names GEODONdoes not cause weight gain but may lead to abnormalities on electrocardiogram (my dad was given multiple doses of this)

Antipsychotic Drugs: How Do They Work?

Antipsychotic drugs appear to be most effective in treating hallucinations, delusions, disorganized thinking, and aggression. Although antipsychotic drugs are most commonly prescribed for schizophrenia, they appear to be effective in treating these symptoms whether they arise from mania, schizophrenia, dementia, or acute intoxication with a substance such as amphetamines.
Antipsychotic drugs work by influencing how information is transmitted between individual brain cells. The adult brain is made up of more than 10 billion individual cells called neurons. Each neuron in the brain has a single long fiber called an axon, which transmits information to other neurons. Like wires connected in a vast telephone switchboard, each individual neuron makes contact with several thousand other neurons.
Information travels down a cell's axon as an electrical impulse. When the impulse reaches the end of the axon, a tiny amount of a specific chemical called a neurotransmitter is released to pass information on to the next cell down the line. A receptor on the receiving cell detects the neurotransmitter, which causes the receiving cell to generate a new signal.
Symptoms of psychosis appear to be caused by excessive activity of cells sensitive to the neurotransmitters dopamineSome Trade Names INTROPINand serotonin. Therefore, antipsychotic drugs work by blocking receptors so that communication between groups of cells is dampened.
Different antipsychotic drugs block different types of neurotransmitters. Every effective antipsychotic drug known blocks dopamineSome Trade Names INTROPINreceptors. The new antipsychotic drugs (risperidoneSome Trade Names RISPERDAL, olanzapineSome Trade Names ZYPREXA, quetiapineSome Trade Names SEROQUEL, ziprasidoneSome Trade Names GEODON, and clozapineSome Trade Names CLOZARIL) may be more effective because they also block serotonin receptors. They also appear to cause fewer side effects.

Story of Donn

This is the story of Donn Anderson and his trip to the hospital, nursing home, and back to the hospital. This blog post is a collection of emails that I've sent out during my dad's time away from home. The red lines are separations between emails. The dashes are times when I started to write an email, got an update, and put more, newer information in the same email. It doesn't really matter, I guess. It's all the same information.
As of last night, April 30th 2008, my dad was basically in a medically induced coma. I asked his nurse what the difference was, and one of the medicines is the same, but a different dose, and they have a second medicine that they don't usually use for the coma. So it's very similar. It's scary to see him in this state; tubes, wires, lines, etc., but it's a relief because he's finally resting. It's been so long since he's actually been able to sleep without tremors. It's actually been so long since he's been able to sleep at all.
His pneumonia is being treated with antibiotics and his fever gradually lowered last night.
4 out of 5 of his doctors have said that they think he has Serotonin Syndrome (info below). His 5th doctor, his psychiatrist, says that he thinks it's neuroleptic malignant syndrome. Information is listed for both in the article below. The "tables" aren't really tables. I can't get them to paste correctly, but there's a link here and at the bottom of this page to the original website.
The first email is one that I sent out to new people, as requested by my mom, so there's an update and background. I realize a lot of this is repeated, but I just copied and pasted info from other emails.

*************************************************************

[April 30, 2008]

Hello-On behalf of my parents, Donn & Kayrene Anderson, I'm sending out an email with a medical health update on my dad. Some of you may have already received this from other people (I just got your email addresses from my parents' email accounts), but just in case you haven't, here it is.

My dad is staying at Edward Hospital in Naperville, IL. He first was admitted late Saturday night, April 19th. Then he was released on Friday night, April 25th and sent to Snow Valley Nursing home for physical therapy. My mom first had him brought in because he had been shaking so much he couldn't sleep and had trouble even moving. The final point was when they decided my mom would drive him to the ER, but he felt like his feet were glued to the ground, so they had to call an ambulance to bring him in. The doctors said that he had Hydrocephalus, a condition where too much spinal/brain fluid is around his brain. Then they said that the tests over the week showed that he didn't have it, and he just needed physical therapy at Snow Valley to help him walk again. They were pretty vague. He spent the weekend at Snow Valley and started to walk again with the help of a walker, but early on Monday morning he was shaking (like a tree) again and couldn't walk or communicate with anyone.

He was again admitted to Edward and we were told a handful of different problems that he might have. He was brought down to the ICU yesterday and this morning was given a diagnosis. Following this is an email I sent out earlier today describing his condition. Since this email has been sent, he was given an arterial & central line because the PICC line couldn't be put in due to his small veins. I'm going to send you ALL of the emails I've sent out and then at the bottom are some articles about his condition: Serotonin Syndrome.

His doctor recently used the phrases "touch and go" and "critical condition". My mom doesn't seem THAT concerned (I asked her if I should leave work early and she said "not yet") right now, but that's because the doctor said that my dad was touch and go, and is now just critical. It's still scary to hear those words. I know it's a lot to read, so the first part is the latest email, and it goes back from there. If anyone has Ron and or Mary Ellen Durbin's email addresses, can you please send this along? My mom asked me to try to send it, but the email address is at home on a piece of paper, and not in her email account. Please feel free to send this along to anyone else I may have missed. Thank you so much!

************************************************************

New News:
[April 30, 2008]
Last night my dad was having a really hard time breathing, so they put a mask on him instead of the tube around/under his nose. Because he's been so out of it they haven't been able to give him his inhalers which help with his COPD and emphysema. His breathing became raspy and he looked like he'd just run a marathon; he'd been breathing so hard. So around 11-ish they put a breathing tube in. With the sedative they gave him, his body calmed down almost instantly. That was good to see. It looked like, for the first time in over a week, he was finally sleeping. They purposely, medically paralyzed him in the middle of the night to calm his body down even more because his breathing was still too fast for their liking.
He's been running a fever for a few days, and it turns out that now he has pneumonia. So they're battling that.
He also has a new diagnosis: Serotonin Syndrome. Mike said that it's when psychoactive drugs not reacting with the body well, and causing the body distress. They're giving him an antidote, but Mike didn't have his notes with him so he couldn't tell me the name of the drug. He said that my dad's calm and peaceful.
They did ultra sounds of his legs and showed that there are no blood clots. They also put him on blood thinners to make sure he doesn't obtain any blood clots.
They put a picc line in, and Mike kind of described it as a line that runs from his arm to his heart, and that's supposed to help feed him, although I don't really understand how that works.
[From my new favorite website- http://www.webmd.com/: A central venous catheter, or vascular access device (VAD), is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. PICC line. A peripherally inserted central catheter, or PICC line (say "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest. ]
They called in a cardiologist because of concern for his heart rate, and they did a 2-D echocardiogram and it showed that his heart is not enlarged. Mike said that my dad was much better at 10am than he was at 6.
Mike and my uncle Dave are obviously exhausted, but sound relieved that there's a diagnosis and they know how to treat it. Mike and Dave have already spoken to 4 out of 5 of my dad's doctors.

***********************************************************

[April 29, 2008]
Gooooood morning! It's about 2:30am here in beautiful Edward Hospital. No real changes with my dad. We're taking turns "sitting" with my dad. He needs a sitter 24/7 so we're taking turns. Amy and I had our turn for awhile and then she woke Mike up and she left. Mike's upstairs with my dad now while I take a break. Surprisingly I'm not sleepy at all. So that's good. I can go back upstairs and help out. My dad hasn't really slept. He got some Valium at 11:05 (i took notes on the nice little pad given to us by the hospital) and it lasted for about half an hour. He got a really good sleep for 15 minutes, kinda woke up and rested for a little longer. Then they gave him some haldol and that didn't really do much. It slowed the tremors a bit, but he's still not sleeping. He's not sure what's going on and when I ask him if he knows where he is he can kind of mumble, "Sure I know" and then when I ask him where he is, he mumbles even more and I just can't figure out what he's saying. He's going to see a few doctors in the morning so hopefully we'll get some answers. Right now, though, I think we're just waiting it out. We were told that he's going through withdrawal from some medicine, but everything has changed within the past few days, so we can't really say for sure what he's withdrawing from.

They have nice cyber centers all around the hospital but I'm not used to this keyboard so I keep making typos. So I'm going to go now. More info later when I get it. Ta ta!

***********************************************************

[April 28, 2008]
Hello All!My dad moved from Edward Hospital to Snow Valley Nursing home on Friday night. It's partially good news because he was "too healthy" to go to Marionjoy. (I still haven't learned if it's Marionjoy or Marion Joy or something else, but I guess it doesn't really matter anymore because he's not going there.) He wasn't able to see a physical therapist over the weekend, so Mike and Joe will have an update hopefully today. As of last night we didn't know how long my dad is supposed to be there or what other things we should expect. My dad's walking with a walker, which is great. He doesn't need help walking around and he was able to lower himself into a chair yesterday while his brothers Tim & Dave visited. He needs more help getting out of bed, but I'm sure that will get better with time. My mom was reading her Merck Manual (the book that "transforms the language of the professionals' version into commonly used English while retaining the vital information about diseases, diagnosis,etc"- from the Merck Manual website) last night and in addition to having all of the symptoms of Hydrocephalus, he also has all of the symptoms of advanced kidney disease. So- they're very similar. My dad had already highlighted a lot of the symptoms in the book. Hopefully they'll hear from a doctor soon to answer the many, many questions that have come up over the weekend.
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I wrote that this morning and then got an update from Joe:My dad got a lot worse overnight. He can't walk on his own and is having great difficulty talking. It takes a long time to get words out and when he does, many times it's slurred or mumbled. So they took him by ambulance back to Edward Hospital. The doctor at Snow Valley was very concerned with my dad's quick decline so he sent him back to the hospital. Mike rode with my dad in the ambulance. As far as I know, Joe followed, my mom left work and drove separately, and my uncles Tim, Dave and Kyle are driving over to the hospital. Hopefully doctors at Edward will answer more questions. Joe said that Mike was taking very detailed notes. That's all I have for now.

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[April 25, 2008]
News:

My dad will be released today. He does not have hydrocephalus. His latest test revealed that the fluid around his brain is now at a normal level. He just had problems that were caused by his kidneys. Marionjoy will not accept him because he's not that bad, I guess. So the hospital is calling around to find a place for him to go, because he's not quite ready to go back home. My mom's phone kept cutting out- she was calling from somewhere in the hospital, so I didn't hear where they're trying to place him, which doesn't really matter either way. He'll be going to rehab to strengthen his legs. So that's good. She's not sure what they're going to do about his confusion; maybe that will just clear up with a little more time. She's very thankful that he won't have to get the shunt put in. Yay!


I'll let you know when he's placed somewhere, and what the duration of his stay will be.

Thanks for all of your good thoughts and prayers!

love,
kt

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[April 24, 2008]

Hello All-My dad was very happy to hear that he has so many people saying hi and praying for him and wishing him well. (Side Note: I apologize for having missed some people's emails. I'm not used to sending out emails to so many people on gmail. Comcast has a different system, so I'm still getting used to the gmail format. Andersons- the aol email address I have for Kyle doesn't work. Suggestions? Thanks)My dad seemed much better today. More awake, more chipper. Not a whole lot to report. (I keep saying that and then, suddenly, there is). He went downstairs last night for a 2nd MRI of his shoulder (3rd overall) and it didn't work out. But when I asked why, we were interrupted by a nurse, then Danny, my mom and I went downstairs for dinner and I asked her a ton of other questions, and forgot about the MRI question until just now. He did have a Cisternography: [I got this from the webmd article: This test is much more involved than CT scan or MRI and is not widely used. It highlights absorption of the CSF. (cerebrospinal fluid)]. So they had to insert a needle to inject him with radioactive isotopes and then he had to lie flat for 2 hours. Then they took him downstairs (I keep saying downstairs- I've never been to whatever rooms they keep taking him to- they may be upstairs. Perhaps I've made "downstairs" up in my head. Perhaps they really do go downstairs. Alas, I digress) for 2 other tests, or completions of the cisternography. I'm not sure if it's 3 separate things, or 3 parts of a whole. They had to inject the dye/isotopes/stuff, then view it, and I think view it again. They took him downstairs right as Danny and I were going up to his room to say goodnight. So that timing worked out for us.
I still don't know when the spinal tap is scheduled. I do know that my mom's going back to work tomorrow. Amy and Emma will be visiting my dad tomorrow, as will Danny and I. So I will have MORE ANSWERS! Yay! *happy answers dance*Ok, so this ended up being pretty short. Excellent.Thanks again!

love,kt

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Recap:
[April 21, 2008]
My dad's staying at Edward Hospital in Naperville. He's got a sketchy diagnosis and a kind of strange problem. On Saturday afternoon, he was shaking a lot and his legs were weak and he was having trouble breathing. By the time he got dressed and ready, and they got to the hospital, his symptoms had subsided, and they figured that it would be kind of a waste of time to go into the hospital if they couldn't show the drs. my dad's problem. They would just see his dr. on Monday morning.Late Saturday night it started again. My uncle John said that my dad was "completely rigid throughout his body, but was shaking the way you would shake a rag doll." He said it was just strange the way his body was stiff, but also shaking a lot at the same time. John has seen people have seizures, and said this was similar (but didn't want to say that he thought my dad had a seizure; just that he needed a way to describe it to us), but my dad was standing upright and his eyes were open and he seemed to be conscious. He was awake, but doesn't really remember any of it now that it's over. He was standing over the stairs and when he tried to move forward or backwards to walk to the car, he couldn't move. So my mom called 911.
The neurologist at Edward said two things: it seems that while my dad was slowly weaning himself off of one anti-depressant (ordered previously by his psychiatrist), it was causing the trembling/shaking. (My mom found some information on that drug and that is one of the "unlikely but possible" side effects) The second thing was that his legs were weak because he was anxious about falling down. This seems like a stretch, because he has this happen from time to time, and then he can walk a few minutes later. It happened when I was out there last weekend. He walked around all day, fine, and then at dinner tried to stand up and his legs almost went out from under him. It was a large effort for him to sit back down again and he hadn't even moved his feet. But then after sitting for awhile he was fine to walk around again. So I'm not sure about the anxiety part. That sounds odd. But, as you all know, I've never been to medical school.I don't really have a good update. His neurologist said that he thought the tremors/severe shaking were from a medicine that he's not taking anymore (as of late Saturday night) and the problem standing/walking is anxiety because he's afraid of falling. I really have a hard time believing that, because he had trouble standing up last weekend, and he walked all day and was fine, then he had trouble, so he sat down for awhile, and then got up and walked around fine. When the neurologist was in my dad's hospital room, he got my dad to stand up and take a few steps. But a couple of hours later when he needed to move from the bed to a chair so close it was almost touching the bed, he couldn't make it on his own. And then when he sat down he was exhausted. Severely winded. He's going to have an MRI sometime this morning but isn't sure what time. Basically I've got a lot of vague answers. But the medicine that he discontinued does have tremors listed as "rare but possible side effects". It's just a concern because it seems that without that medicine he's very irritable and combative. Hopefully it will even out later today. Maybe he'll feel better after he's had breakfast & lunch (I talked to my mom on the phone around 9) and after the MRI.
I'll send more updates later whenever I get them.

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Newer update:I just called the hospital (first my dad's room, then my mom's cell) and my dad got up last night to go to the bathroom (BY HIMSELF) and fell and hurt his shoulder. Many nurses were able to come to his aid quickly to help him up. He hasn't gotten up and walked around since. They were both very quick on the phone so I didn't get a LOT of details. He's already had the MRI of his brain, and they're going to do an MRI of his shoulder later today. He's had a bad shoulder for a long time, and I'm not sure if this is the same one, or the other one.When I spoke with my mom, she said that there was an occupational therapist there right now, and a physical therapist will be there later today to check him out. His kidney doctor said today that he's seen these reactions to this medication (I can't remember the name, I'm 99% sure it's Celexa.) in other kidney patients. That's good. Second opinions are always good. My mom's still not sure about the weakness in his legs. She said she'd call me later with updates. It sounded like it was really busy in his hospital room, so they didn't want to stay on the phone long.

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Ok, so as it turns out the MRI showed that my dad has Hydrocephalus. You can click on that link and it goes to webmd.com. The article is about "Normal Pressure Hydrocephalus", but my mom didn't give me anything besides the word hydrocephalus, so I'm not sure if it's normal or not. Hopefully the more I type hydrocephalus, the easier it will be for me to remember how to spell it. Anyway, it occurs when there is too much spinal fluid around the brain. It has these really interesting symptoms that my dad also has:
Dementia symptoms* Memory loss* Speech problems* Apathy (indifference) and withdrawal* Changes in behavior or mood* Difficulties with reasoning, paying attention, or judgmentWalking problems* Unsteadiness* Leg weakness* Sudden falls* Shuffling steps* Difficulty taking the first step, as if feet were stuck to the floor* "Getting stuck" or "freezing" while walkingSo that's pretty good- it's a serious condition, but he's going to have a spinal tap at some point. My mom wasn't sure when. I think she was saying that the hydrocephalus was brought on by use of the Celexa in conjunction with other meds and his kidney disease...I'm not sure. That looks strange now that I've typed it out, but she was given a lot of information in a short amount of time, and I didn't write everything down that she said, so I may have mixed things up. I'm sure about the hydrocephalus, though. It would be nice if they would have it all written out for her, but it didn't happen that way.After he fell and hurt his shoulder, they tried to adjust him to get him to fit into the MRI machine, and they yanked on his shoulder again, which made him really, really angry. He apparently chewed out his nurse (she didn't do it, but he needed someone to yell at), and she totally took it in stride. I'm glad they put her with him. He went through the first MRI fine. He was upset about his shoulder hurting, but was able to get some pain medicine and calmed down. When Danny and I got to the hospital this evening, he was out of his room- downstairs getting an MRI of his shoulder. It didn't work. He had gotten very upset about just being in the MRI machine and worked himself into a sweat and "didn't fit" so they brought him back upstairs to his room. The technician said that she could see that he was in a lot of pain. His nurse asked him how he fit into the MRI machine the first time. He swore up and down that this was a different machine, different size, blah blah blah. Edward hospital has 2 machines and they're exactly the same and they're in the same area, just separated by an office. He wasn't sure. Then he couldn't remember actually going into the MRI. He remembered telling my mom that he liked the ping-ing noise that the machine makes, but didn't remember actually lying down for the test. The nurse talked him into going to do the MRI for his shoulder a second time around 7:30. She said that she'd give him drugs at 8, and they'd come to pick him up at 8:30 and he'd be fine, so he agreed. Danny and I left around 8, and my mom left a little while later, and doesn't know how the MRI went. I just called my dad's room and there's no answer, so either he's still doing the MRI, or he's asleep.
When he's done with his stay at Edward, (and they don't know when that will be) he will be staying at another facility for rehab-learning to walk and for his shoulder, and some other things. My mom's not sure how long he'll be there, either. Hopefully they'll have some more concrete answers tomorrow. My mom needed to get some sleep and she'll be back to the hospital tomorrow. She took a LOT of time off of work last month when she was in the hospital with pneumonia, so cross your fingers that her boss doesn't give her crap for taking more time off. I don't think they will, but extra good luck fingers couldn't hurt. I'm glad he's in the hospital now when many of his symptoms are visible so the doctors can help. It's a lot easier than my mom just telling a doctor that he's got a poor memory. He calls me Sheila a lot, but usually corrects himself right away, but he didn't correct himself today. Then he didn't remember the MRI, and some other things that happened throughout the day. I have a good feeling that this will work out well for him, and my mom seems upbeat, just kind of confused and overloaded with information. At least now we have some things straightened out.I know there are a lot of holes in this, but hopefully I'll get everything filled in soon.

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This is from a blog on webmd:

Poly-pharmacy or the use of multiple drugs to treat a condition has always been a situation that bears watching. In some conditions drugs are purposely prescribed in combination in order to create a synergistic affect - leading to a more effective outcome in symptom management or resolution. There are times however, when a combination of drugs can be lethal if not watched carefully. In these situations, it is important for doctors to have a heightened awareness of these potential complications and avoid prescribing such combinations for their patients. One condition that seems to be on the rise again is serotonin syndrome and it is seen most often in patients being treated for migraine headaches because of the combination of drugs involved. This syndrome is a result of too much serotonin in the body and it presents with a variety of symptoms that resemble neuroleptic malignant syndrome--a serious condition seen in patients taking neuroleptic drugs.
This article is very good as well. It has a bit more clinical information related recognition and management. It contains lists of specific drugs to be aware of. It also includes some case studies and differential diagnosis information I think might be interesting and helpful. If you find you are taking any medications or have any concerns about your medication regimen, I encourage you to talk to your physician promptly and discuss appropriate alternatives.
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"This Article" as referenced in the above blog is here. It's really long and I haven't read even half of it, but here it is.

Serotonin Syndrome: Recognition and Management
http://www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/acf2fa6.htm
Steve Nolan, Pharm.D. Resident, University of Tennesesee College of Phamacy and William F. Bowld Hospital, Memphis J. Allen Scoggin, Pharm.D., MPA Associate Professor of Pharmacy Practice and Pharmcoeconomics, University of Tennessee College of Pharmacy, Memph
Serotonin syndrome is described in the literature as a potentially serious drug-related condition characterized by a number of mental, autonomic and neuromuscular changes.1 Although serotonin syndrome can cause death, the condition is mild in most persons, and with supportive care alone they tend to recover completely. The syndrome, first described in animal models in the 1950s, was referred to as the "serotonin behavioral" or "hyperactivity syndrome."1
Reports of serotonin syndrome in humans followed, and have become increasingly frequent since the 1960s. The earliest reports involved persons who were taking monoamine oxidase inhibitors (MAOIs). Some of the early reports included patients who were also taking tryptophan, a serotonin precursor.1,2
Serotonin syndrome is most often reported in patients taking two or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, selective serotonin reuptake inhibitors (SSRIs), and the tricyclic antidepressants.3 Because of the dramatic rise in the use of SSRIs, it is predicted that emergency room physicians are going to encounter the serotonin syndrome more frequently than in the past.1 Symptoms associated with the condition appear in TABLE 1.

TABLE 1.
Symptoms Associated with Serotonin Syndrome
Mental status changesConfusion (51%)Agitation (34%)Hypomania (21%)Anxiety (15%)Coma (29%)
CardiovascularSinus tachycardia (36%)Hypertension (35%)Hypotension (15%)
GastrointestinalNausea (23%)Diarrhea (8%)Abdominal pain (4%)Salivation (2%)

References 2, 4
Motor AbnormalitiesMyoclonus (58%)Hyperreflexia (52%)Muscle rigidity (51%)Restlessness (48%)Tremor (43%)Ataxia/incoordination (40%)Shivering (26%)Nystagmus (15%)Seizures (12%)
OtherDiaphoresis (45%)Unreactive pupils (20%)Tachypnea (26%)Hyperpyrexia (45%)


Several other medications can precipitate the serotonin syndrome (TABLE 2). Increased reporting of cases appears to be related to at least three things: recently published diagnostic criteria describing serotonin syndrome; greater use of antidepressant medications, such as the SSRIs; and an increased attempt by physicians to differentiate serotonin syndrome from neuroleptic malignant syndrome.4

TABLE 2.
Drugs that Affect Serotonin Levels
Effect
Drug
Increase serotonin synthesis
L-tryptophan
Decrease serotonin metabolism
isocarboxazidphenelzineselegilinetranylcypromine
Increase serotonin release
amphetaminescocainereserpine
Inhibit serotonin uptake
amitriptylineclomipraminedesipraminedoxepinimipraminenortriptylineprotriptylinefluvoxaminefluoxetineparoxetinenefazadonesertralinetrazodoneamphetaminescocainedextromethorphanmeperidinevenlafaxine
Direct serotoninreceptor agonists
buspironelysergic acid diethylamide(LSD)sumatriptan
Nonspecific increase inserotonin activity
lithium
Dopamine agonists
amantadinebromocriptinebupropionlevodopapergolidepramipexole
References 2, 4

Mild to moderately severe cases of serotonin syndrome usually resolve in 24 to 72 hours.1 Though most cases can be treated and resolve within a week, some patients become acutely ill and require hospitalization. In some instances patients have been admitted to the ICU and required mechanical ventilation. Mortality associated with this condition is estimated to be 11%.4

Serotonin Receptors

Serotonin (5-HT; 5-hydroxytryptamine) occurs naturally in the body. In the periphery, serotonin acts both as a gastrointestinal regulating agent and a modulator of blood vessel tone.5 Although only 2% of the body's serotonin is found in the brain as a neurotransmitter, the chemical can have a profound effect on body functions. As a neurotransmitter, serotonin is involved in the modulation of motor function, pain perception, appetite, and outflow from the sympathetic nervous system.4
Serotonin acts at receptors generally classified into one of four categories, depending upon function and location. The four recognized serotonin receptors identified are 5-HT1, 5-HT2, 5-HT3 and 5-HT4. Receptor subtypes also have been identified. For example, the 5-HT1d subtype lies outside the CNS and is the receptor through which sumatriptan exerts its antimigraine effect. Researchers agree that the majority of signs and symptoms associated with serotonin syndrome involve excessive stimulation of the 5-HT
1A receptor.1,6 Recent studies, however, show that the 5-HT2 receptor may be at least partially responsible for the serotonin syndrome.1,4 The 5-HT2 receptors are located in the brain and peripheral blood vessels.
Most cerebral functions are the result of the convergence of many different neurotransmitters, including serotonin.7 This complex network of neurotransmitters makes it possible for serotonin to affect many functions and actions of the brain. For example, serotonin often serves as a cotransmitter along with gamma-aminobutyric acid (GABA) and norepinephrine. Serotonin antagonizes GABAB receptors, causing upregulation of this subtype. The activity of benzodiazepines in the treatment of serotonin syndrome is thought to occur because these compounds act as strong agonists at GABAB receptors. Certain dopaminergic neurons have serotonin receptors, resulting in serotonin-modulated release of dopamine in different areas of the brain.

Serotonin Syndrome Risk Factors

Risk factors for the development of serotonin syndrome are unclear, but some trends are becoming apparent as more cases appear in the literature. Some researchers have suggested that peripheral vascular disease and atherosclerosis may lead to severe vasospasm and hypertension in the presence of elevated serotonin levels. This seems paradoxical, since in peripheral areas of the body serotonin usually causes vasodilation. However, in patients with vascular disease serotonin can lead to profound vasoconstriction.6
Another risk factor relates to drug metabolism rate. Slow metabolizers of SSRIs (approximately 7% of the population) may produce higher than normal levels of these antidepressants in the blood. A slow metabolizer receiving an SSRI in combination with another agent that raises serotonin levels is therefore at increased risk of developing serotonin syndrome.
6

Clinical Features and Differential Diagnosis

Mental status changes are the most frequently reported symptoms associated with serotonin syndrome.2 Other commonly reported features include motor abnormalities, cardiovascular changes, gastrointestinal problems and miscellaneous changes such as diaphoresis and fever (TABLE 1).2,4 Martin refers to three categories of symptoms that are present: altered mental status, autonomic dysfunction and neuromuscular abnormalities.1 Sporer indicates that at least three of the following must be present for a diagnosis: mental status changes, agitation, myoclonus, hyperreflexia, fever (hyperpyrexia), shivering, diaphoresis, ataxia and diarrhea in the setting of a recent addition or increase in dose of an agent that raises serotonin levels. Sporer also points out that there should be no other obvious causes of the confusion and/or fever, and that no antipsychotic medications have been used or increased in dose prior to the onset of symptoms.3
Poisonings and other diseases, such as neuroleptic malignant syndrome (NMS), can cause symptoms that are very similar to serotonin syndrome (TABLE 3). Martin offers suggestions that may be useful in differentiating serotonin syndrome from these conditions. One is an observation that bromocriptine has been proposed as a treatment for NMS and a cause or precipitant of serotonin syndrome. Another is that NMS occurs from prolonged exposure to neuroleptic agents or withdrawal of dopamine agonists, and there is lead-pipe rigidity with NMS, in contrast to myoclonus or hyperreflexia seen in persons with serotonin syndrome.1

TABLE 3.
Differential Diagnosis of Serotonin Syndrome
Diseases
Poisonings
Catatonia
Anticholinergics
Dystonia reaction (severe)
Amphetamines
Encephalitis
Cocaine
Hyperthyroidism
2,4 dichlorophenoxyacetic acid
Malignant hyperthermia
Dinitrophenol
Meningitis

Lithium
Neuroleptic malignant syndrome
LSD
Septicemia
MAOIs
Stiff-man syndrome
Pentachlorophenol
Tetanus
PCP (phencyclidine)SalicylatesStrychnine Water hemlock
Reference 1

Medications Linked with Serotonin Syndrome

Causative agents associated with serotonin syndrome include those that: increase serotonin synthesis (L-tryptophan); decrease serotonin metabolism (MAOIs); increase serotonin release; inhibit serotonin uptake (SSRIs); and stimulate certain serotonin receptors directly, and provide a nonspecific increase in serotonin activity (TABLE 2).
The largest number of cases reported in the literature and the most serious consequences of serotonin syndrome have resulted from use of the MAOIs.3 Most cases were reported when an MAOI was used in conjunction with meperidine, tryptophan, dextromethorphan (an ingredient in many over-the-counter products), a tricyclic antidepressant, or an SSRI antidepressant.2,3 The long half-life (SSRIs) and duration of effect (irreversible MAOIs) seen with some of these medications increase the possibility of serotonin syndrome occurring several weeks after these drugs have been discontinued.1 It is important to note that serotonin syndrome has been precipitated by medications that are not usually thought of as being serotonergic. One author asserts that both meperidine and dextromethorphan are "notorious for precipitating acute serotonin syndrome."4

Case Reports

Select cases of suspected or confirmed serotonin syndrome illustrate the broad range of circumstances in which this condition can occur. Although there are many reports of "possible" serotonin syndrome reactions in the literature, in many instances the syndrome is not fully developed as there may be question as to whether the symptoms reported are really the result of serotonin syndrome. In such instances the diagnostic criteria developed by Sternbach, Martin and Sporer should be followed.1-3

Case No. 1:A case reported in 1994 involved a 48-year-old man brought to the emergency room due to agitation and confusion. He had a three-year history of depression which was being treated with tranylcypromine (Parnate), an MAOI. The tranylcypromine was discontinued prior to E.R. presentation. Fourteen days after the MAOI was discontinued, fluoxetine (40 mg daily) was begun. Over the next 72 hours the patient developed agitation, diaphoresis and confusion. During his hospital stay he developed tachycardia and profound muscle rigidity and had to be intubated. In addition to supportive measures, the patient received diazepam and propranolol to relieve muscle rigidity, hypertension and tachycardia. By the third hospital day his temperature returned to normal and he rapidly recovered. He was released on the fifth day.
8
This case underlines the extreme importance of implementing a "wash out" period after the discontinuation of one serotonergic drug before the implementation of another. Even after two weeks, the effect of tranylcypromine was still active enough to cause a serotonergic crisis when therapy with fluoxetine was begun.

Case No. 2: A 72-year-old man was admitted to the hospital for presumed Parkinson's disease and depression. He was placed on selegiline and fluoxetine. After nine weeks of treatment, he presented with acute delirium which progressed to lethargy, malaise, myoclonic jerking and grand mal seizures. The fluoxetine was discontinued, but seven days later he experienced acute delirium, convulsions, and became unresponsive. The selegiline was discontinued. Five days later symptoms resolved completely.9 This case demonstrates the ability of fluoxetine to exert its serotonergic effects for a few days up to weeks after discontinuation. The effect probably is due to the long half-life of both fluoxetine and its active metabolite, norfluoxetine.

Case No. 3: A recent report describes a 51-year-old man who developed serotonin syndrome when he combined Nyquil with paroxetine (Paxil). Pertinent medical history included depression, for which he was taking paroxetine, and peripheral vascular disease. Four days prior to admission, he developed nasal congestion which he self-medicated with Nyquil. Two days later, he experienced nausea, extreme shortness of breath, and confusion. Upon admission to the hospital he was experiencing tachycardia and his blood pressure was 202/110. During hospitalization the patient became rigid and more confused. Potential causes of symptoms, including strychnine poisoning, anxiolytic withdrawal and tetanus were ruled out (
TABLE 3). Administration of lorazepam resolved all symptoms, and he was transferred to the ICU with normal mental status. The paroxetine was discontinued, and after a four-week follow-up, the patient remained asymptomatic.5
The most probable explanation for the development of serotonin syndrome in this patient was the combination of dextromethorphan (an ingredient in Nyquil) and paroxetine. The pseudoephedrine in Nyquil (10 mg/5 mL) may have produced the adrenergic effect (e.g., increased blood pressure). In addition, the vascular disease may have been a predisposing factor. Dextromethorphan inhibits reuptake of serotonin (TABLE 2) and has previously been implicated in serotonin syndrome when combined with an MAOI.4,5 It has been shown that persons with a history of vascular endothelial damage are at risk of vasospasm in the presence of increased serotonin levels.1 The authors of this case report suggest that patients with pre-existing vascular disease may be at increased risk of developing complications related to increased serotonin levels. As a result, caution should be exercised when administering serotonergic medications to patients with vascular disease. If possible, such patients should consult a physician or pharmacist before self-medicating with over-the-counter cough medicines.

Case No. 4:The newer antidepressants may pose a potential problem as well. For example, nefazodone (Serzone), blocks 5-HT2 receptors and also inhibits reuptake of serotonin. Recently there was a report of a 51-year-old woman with a history of bipolar disorder who was brought to the emergency room unresponsive, diaphoretic, hyponatremic and with muscle rigidity. The patient had taken nefazodone (Serzone) for six months and had just discontinued the drug for two days. One day before admission she was started on paroxetine (Paxil). She improved dramatically after supportive treatment and dantrolene.
10 Although nefazodone is a relatively weak 5-HT reuptake inhibitor, it is still capable of causing serotonin syndrome when combined with a stronger 5-HT reuptake inhibitor. While the researchers who reported this case believe it to be the first case of serotonin syndrome reported from the use of nefazodone and paroxetine, they point to other reports involving the use of trazodone and paroxetine.

TABLE 4.
Pharmacist Management of Serotonin Syndrome
Patient/Prescriber Education
Make certain patients understand potential problems, what they should look for, and what to do if symptoms occur (e.g., muscle spasms, shaking, shivering, sweating, confusion)
Contact prescribers when the risk for serotonin syndrome increases (e.g., concurrent therapy with two or more serotonergic agents). Counsel patients to determine if OTC products containing serotonergic ingredients are being used.
Prevention
Reconsider using two or more serotonergic medications
Consider switching to less serotonergic alternatives
Management


Discontinue all serotonergic medications
Consider benzodiazepines for myoclonus and resultant hyperthermia
Consider cyproheptadine, propranolol, or methysergide if symptoms persist
Provide immediate supportive care as necessary (e.g., therapy for hypertension, tachycardia, hyperthermia, respiratory distress)

Management and Prevention
No specific therapeutic approach to the treatment of serotonin syndrome has been fully evaluated in the literature. The most common treatment involves the use of the benzodiazepines. In severe cases, the antiserotonergic agents cyproheptadine, methysergide, and propranolol have been used.3,6,11 In all cases the suspected agent should be discontinued. Over-the-counter drugs containing ingredients known to increase serotonin levels or exacerbate the patient's condition, such as dextromethorphan, pseudoephedrine or phenylpropanolamine, also should be discontinued.
Initial treatment should consist of supportive measures aimed at reducing hypertension, tachycardia, hyperthermia and respiratory distress if these conditions are present. Lorazepam and diazepam have been shown to be effective in treating myoclonus associated with serotonin syndrome, and in mild cases, are usually the only treatment necessary. It is important to note that clonazepam has been found to be ineffective in treating serotonin syndrome. Unlike diazepam and lorazepam, clonazepam is not a potent agonist of the GABAB receptor.6 The more severe cases that do not respond to benzodiazepines may respond to dantrolene, which may be effective in relieving muscle rigidity and hyperthermia.
1
Pharmacists should recognize potential problems associated with the concurrent use of certain medications, such as the MAOIs and the SSRIs and other agents that can cause serotonin syndrome. Due to the potentially serious nature of this condition, it seems prudent that pharmacists always monitor patients who are taking combinations of serotonergic drugs and be alert to the possibility of "serotonergic duplication" and notify physicians and other prescribers when the risk of drug adversity appears eminent. The use of therapeutic alternatives in certain instances could be life-saving.