Overdose with levetiracetam: a case report and review of the literature.

WHAT IS KNOWN AND OBJECTIVE: Levetiracetam is an anticonvulsant agent that was first approved for use in the United States in 1999 and has a maximum recommended adult dose of 3000 mg daily. It has been noted to have a relatively mild adverse effect profile, with the most common side effects being somnolence, asthenia, infection, and dizziness. Although it has been widely prescribed, there have been few reports on the safety of this agent in overdose. CASE SUMMARY: We present the case of a 49-year-old man who ingested over 22 500 mg of levetiracetam in a suicide attempt. The patient arrived at the Emergency Department 6·5 h after the ingestion and was noted to have no significant sequelae from the ingestion. Based on the patient's weight, he ingested 358 mg/kg of levetiracetam. WHAT IS NEW AND CONCLUSION: The few cases of levetiracetam overdose reported in the literature were associated with relatively mild, if any, symptoms. However, one patient who overdosed on levetiracetam became obtunded and developed significant respiratory distress that required intubation and ventilatory support. Therefore, clinical vigilance is still required in the cases of levetiracetam overdose.

The role of sertraline in a patient with recurrent hyponatremia.

A 75-year-old female with major depression was admitted to the hospital on two separate occasions for medical problems. During both her hospitalizations she was evaluated by a psychiatrist and diagnosed with a major depressive episode. On both admissions the antidepressant chosen to treat her depression was sertraline. Each time the patient was treated with sertraline she developed significant hyponatremia within 7 days of the initiation of therapy. The case is presented and discussed, with special emphasis on the prior reports of hyponatremia associated with sertraline use, and the treatment alternatives.

Acute risperidone overdose.

Risperidone (Risperdal) is a recently released novel antipsychotic medication. It is different from the conventional neuroleptics, such as haloperidol, as it has both serotinergic and dopaminergic activity. It has a more tolerable side-effect profile compared with other antipsychotic medications. We review the literature regarding the side effects of risperidone use, describe a case of overdose with risperidone, and discuss the clinical sequelae and management of such an overdose.

Seizures associated with buspirone overdose: case report and literature review.

Buspirone is a novel anxiolytic agent that is commonly used in the treatment of generalized anxiety disorder. Many studies have found it to be equal in efficacy to the benzodiazepines in the treatment of this illness. Its use has gained favor over the past few years because of its relatively mild and tolerable side-effect profile. The authors report a case of buspirone overdose that resulted in a generalized tonic clonic seizure approximately 36 hours after ingestion. Although there have been no previous cases of seizure induction by buspirone in humans, there are animal models of this phenomenon. The authors describe the case, review the literature regarding buspirone overdose and toxicity, and discuss treatment recommendations.

Sertraline-induced panic attacks.

Sertraline is a selective serotonin reuptake inhibitor that is approved by the U.S. Food and Drug Administration for the treatment of major depression, obsessive-compulsive disorder (in adults and children), and panic disorder. Although numerous studies have found sertraline to be very effective in the treatment of anxiety, there have been few case reports of panic attacks actually being induced by treatment with sertraline. In this article, we present the cases of two patients without any personal or family history of anxiety disorders who developed panic attacks shortly after the initiation of sertraline therapy. We will also review the literature in regard to the development of anxiety symptoms during treatment with the newer antidepressants and discuss the neurochemical basis of these antidepressant-induced panic attacks.

Nefazodone overdose: a case report.

Nefazodone (Serzone) is one of the newer medications developed to treat major depression. It is a phenylpiperazine derivative that inhibits the reuptake of both norepinephrine and serotonin and antagonizes the 5HT2 and alpha-one adrenergic receptors. It is well tolerated by patients, and is felt to have a much wider margin of safety than older antidepressants. We report the case of a woman who attempted suicide by ingesting a large amount of nefazodone and a smaller amount of verapamil. We review the literature regarding nefazodone side effects and previous cases of overdose, discuss the clinical complications of such an overdose and discuss treatment recommendation.

Clozapine induced polyserositis.

Clozapine was approved by the U.S. Food and Drug Administration in 1989 for treatment of severely ill schizophrenic patients. It has activity against both the positive and negative symptoms of schizophrenia, which has made it an alternative to traditional antipsychotic medications such as haloperidol. However, clozapine must be used cautiously due to its side effect profile. These side effects include agranulocytosis, seizures, and cardiorespiratory symptoms. We report the case of a patient who developed polyserositis (pericardial effusion, pleural effusion, and pericarditis) after being started on clozapine, and whose symptoms remitted upon discontinuation of clozapine. The literature is reviewed and the treatment implications are discussed.

Pediatric sertraline overdose.

Sertraline (Zoloft) is a selective serotonin reuptake inhibitor that is commonly used in adults in the treatment of mood and anxiety disorders. Whereas it also is used to treat these illnesses in children, it is not currently approved by the Food and Drug Administration for use in this population. Sertraline use has been increasing secondary to its efficacy and its more tolerable side effect profile than the tricyclic antidepressants. It is also much safer in overdose than the tricyclic antidepressants. Although there have been numerous reports of sertraline overdose in adults, reports in the pediatric population are much less common. We review the literature regarding sertraline overdose in children, describe a case of sertraline ingestion in a 22-month-old infant, and discuss the treatment of such an overdose.

QTc interval prolongation associated with citalopram overdose: a case report and literature review.

Citalopram is a member of the selective serotonin reuptake inhibitor class of antidepressants. In 1998, citalopram was approved by the US Food and Drug Administration for the treatment of major depression. Like the other selective serotonin reuptake inhibitors, citalopram enjoys a relatively benign side effect profile compared with the tricyclic antidepressants and the monoamine oxidase inhibitors. However, citalopram has been associated with electrocardiographic changes and seizures at doses greater than 600 mg per day. Fatalities have occurred with citalopram-only overdoses. We report the case of a healthy 21-year-old woman who developed QTc interval prolongation after ingestion of approximately 400 mg citalopram. We discuss the cardiac effects of citalopram, review previous cases of citalopram overdose, and discuss treatment recommendations.

Central nervous system side effects associated with zolpidem treatment.

Zolpidem is one of the newer medications developed for the treatment of insomnia. It is an imidazopyridine agent that is an alternative to the typical sedative-hypnotic agents. Zolpidem use is gaining favor because of its efficacy and its side effect profile, which is milder and less problematic than that of the benzodiazepines and barbiturates used to treat insomnia. Still, side effects are not uncommon with zolpidem use. We report a series of cases in which the patients developed delirium, nightmares and hallucinations during treatment with zolpidem. We will review its pharmacology, discuss previous reports of central nervous system side effects, examine the impact of drug interactions with concurrent use of antidepressants, examine gender differences in susceptibility to side effects, and explore the significance of protein binding in producing side effects.

The effect of sertraline on routine blood chemistry values.

Sertraline is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. Although SSRIs are believed to have a milder side effect profile than the tricyclic antidepressants, there are some potentially serious side effects. These include hyponatremia, which has been seen with each of the SSRIs. We reviewed the charts of 246 patients treated with sertraline at a veterans' hospital. We obtained values for each patient's basic chemistry panel (sodium, potassium, chloride, glucose, carbon dioxide, blood urea nitrogen, and creatinine) before and after institution of sertraline therapy. We studied the patients' ages and sertraline doses to see if there was a relationship between any laboratory value changes and these variables. We found no relationship between maximum sertraline dose, age, and changes in routine blood chemistry results with the exception of a small (0.5%) contribution of maximum sertraline dose to variance in serum creatinine levels. Sertraline therapy was not noted to cause any significant changes in serum sodium levels.

Atypical antipsychotic overdose in the pediatric population.

Risperidone is an atypical antipsychotic medication commonly used to treat psychotic illnesses in adults. It is being used with increasing frequency in children and adolescents, even though it has yet to be approved for use in this population by the Food and Drug Administration. There are few reports in the literature regarding its safety in those younger than 18 years of age. We present the case of a 15-year-old who ingested 110 mg of risperidone in a suicide attempt and developed only transient lethargy, hypotension, and tachycardia without any other significant effects. We review the literature regarding risperidone overdose in all age groups and review the current literature regarding pediatric overdose with the other atypical antipsychotics currently available in the United States. From those cases it seems that special care may be warranted with all pediatric cases of atypical antipsychotic overdose, including monitoring in a high-intensity clinical setting to manage potential respiratory or cardiac difficulties.

Olanzapine overdose in an 18-month-old child.

Olanzapine is an atypical antipsychotic medication that was approved for use in the United States in 1996. While it is a widely used medication in adults, there has been minimal investigation into its effect on children. We present the case of an 18-month-old boy who ingested 30-40 mg of olanzapine, which resulted in significant symptoms, including respiratory distress and mental status changes. Previously reported pediatric cases of olanzapine ingestion have described similar symptoms. Therefore, the pediatric population should be monitored closely when ingestions of olanzapine occur.

Dystonia associated with crack cocaine use.

Cocaine is a substance that has significant central stimulant action in the central nervous system. As cocaine abuse spreads throughout society, many neurologic side effects are appearing with increasing frequency. These side effects include seizures, tremor, focal neurologic deficits, headache, and dizziness. Recently, there have been reports of movement disorders associated with cocaine use. Cocaine use increases the incidence of acute dystonic reactions in patients being treated with dopamine blocking agents. There have also been rare reports of cocaine causing dystonia in patients who were taking no other street drugs or medications. Our report describes the case of a patient who had an acute dystonic reaction 12 hours after a crack cocaine binge.

Famotidine-associated delirium. A series of six cases.

Famotidine is a histamine H2-receptor antagonist used in inpatient settings for prevention of stress ulcers and is showing increasing popularity because of its low cost. Although all of the currently available H2-receptor antagonists have shown the propensity to cause delirium, only two previously reported cases have been associated with famotidine. The authors report on six cases of famotidine-associated delirium in hospitalized patients who cleared completely upon removal of famotidine. The pharmacokinetics of famotidine are reviewed, with no change in its metabolism in the elderly population seen. The implications of using famotidine in elderly persons are discussed.

Meperidine associated mental status changes in a patient with chronic renal failure.

Meperidine is widely used for pain control in the hospital setting. It is also known for its propensity to cause mental status changes in renally and hepatically impaired patients. A case is reported of a 37-year-old man with chronic renal failure maintained on peritoneal dialysis in whom delirium developed when he was treated with meperidine not only on one occasion but also on two subsequent admissions. The pharmacology of meperidine is reviewed and the implications of using the medication in patients with renal impairment are discussed.

Factitious disorder presenting as bacteremia. Case report and literature review.

A factitious disorder is typically a chronic illness that can be frustrating for the clinical team because it often eludes early diagnosis. Case reports in the literature show that patients can simulate almost any illness or disease state with some resorting to injecting themselves with contaminated substances to produce infection. A case is reported of a patient with self-induced bacteremia who presented with multiple episodes of polymicrobial bloodstream infections. The various types of factitious disorders and a review of treatment options are discussed. The current criteria for factitious disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 4th edition are reviewed.

A survey of United States general psychiatry residency programs: program characteristics and relationship to the 1994 National Residency Matching Program results.

We developed a questionnaire regarding issues in psychiatric residency training and distributed it to the chief residents at all United States general psychiatry residency training programs. We hoped to examine psychiatry residency program characteristics and see if any particular characteristics had a significant relationship to improved success in the 1994 National Residency Matching Program (NRMP) results. We found that those programs with six or more PGY-1 positions available in the NRMP, those programs with an associated child and adolescent psychiatry residency training program, and those programs offering a research elective had a higher PGY-1 match through the NRMP than programs without these features.

Report of a case of male genital self-mutilation and review of the literature, with special emphasis on the effects of the media.

Genital self-mutilation is seldom reported; fewer than 100 cases have been reported in the literature to date. Few studies have examined the factors that may lead susceptible individuals to undertake this act. We report here on a case of genital self-mutilation by a 22-year-old man who cut off his penis with an electric chain saw. This patient, who also demonstrated borderline intellectual functioning as evidenced by psychological testing, was likely influenced by the popular media, which was showcasing the criminal trials of John and Lorena Bobbitt at the time of the patient's act.

Delusions about the Internet.

As computer use increases throughout the world, more people are becoming familiar with computers, the Internet, and the roles that both play in their daily lives. There have already been reports of people becoming addicted to the Internet, and we now report on two cases of men who had delusions that they were controlled by and entwined with the Internet. We feel that this phenomenon is not a new diagnostic entity but more likely a new subtype of previously reported psychiatric illnesses. We also discuss the genesis of delusional content and how topics covered in the popular media may influence delusional content.