Serotonin syndrome following overdose of a non-prescription slimming product containing sibutramine: a case report.

INTRODUCTION: Non-prescription slimming products are popular and can be easily purchased from the Internet. However, adulteration of these products with undeclared substances including prescription drugs is not uncommon. We report a case of serotonin syndrome after an overdose of a non-prescription product containing sibutramine. CASE REPORT: A 21-year-old woman presented with somnolence, sinus tachycardia, generalised increase in tone, hyper-reflexia and clonus more prominent in the lower limbs after an intentional overdose of a non-prescription slimming product obtained from the Internet. The product was later found to contain sibutramine and other substances such as animal thyroid tissues, caffeine and phenolphthalein. Quantitative analysis of patient's serum on presentation revealed a sibutramine concentration of 112 ng/mL, which far exceeded the reported peak serum concentration after a single oral dose of 15 mg (the maximum daily recommended dose). No other culpable agent was identified. The overall clinical presentation was compatible with serotonin syndrome associated with sibutramine overdose. The patient made a full recovery after supportive management. DISCUSSION AND CONCLUSION: This case highlighted the health threat posed by non-prescription slimming products sold over the Internet. Sibutramine overdose can result in serotonin syndrome, as in overdose of other serotonergic agents. Early recognition and timely supportive treatment are essential to ensure a good clinical outcome.

A retrospective review of California poison control system data of sibutramine exposures.

INTRODUCTION: Sibutramine is a centrally acting neurotransmitter reuptake inhibitor used for the treatment of obesity. In doses of 10-15 mg/day, sibutramine has been shown to promote modest weight loss; however, the literature devoted to characterizing overdoses and abuses of sibutramine is limited. METHODS: We queried and retrospectively reviewed the California Poison Control System database between January 1998 and August 1, 2008. This was an observational case series. RESULTS: A total of 62 cases were identified. Forty-four (71%) of our study subjects were females. Twenty-three patients (37%) were between 8 months and 2 years of age; 17 patients (27%) were between 31 and 50 years. The doses ranged from 2.5 to 75 mg. A total of 27 patients (44%) were referred to a medical center. In general, medical outcomes were minor. Twenty-five (40%) patients had no effects reported; 30 patients (48%) reported minor effects; and three patients (5%) had moderate effects. There were no major effects or deaths reported. In 58 (94%) patients, the ingestion was unintentional. Thirty-two (52%) cases resulted in the recommendation of observational therapy only as their management strategy. Of the patients who did experience adverse effects, cardiovascular side effects were the most common. In particular, tachycardia (nine patients, 14.5%) was the most notable, followed by chest pain (four patients, 6.5%). Six patients (10%) reported central nervous system side effects. Gastrointestinal side effects occurred in four patients (6.5%). The dose ingested did not appear to correlate with the clinical effects observed. DISCUSSION: Sibutramine ingestion resulted in no serious effects or deaths on our retrospective case series. Mild to moderate effects that were rarely reported included tachycardia, chest pain, agitation, irritation, dizziness, vertigo, nausea, and vomiting.

Serotonin syndrome following sibutramine poisoning in a child, with sequential quantification of sibutramine and its primary and secondary amine metabolites in plasma.

OBJECTIVE: To report a case of serotonin syndrome (SS) after sibutramine overdose in a child. CASE REPORT: A 4-year-old girl was admitted 25 h after accidentally ingesting approximately 27 pills of sibutramine (15 mg, approximately 23 mg/kg). The child developed clinical features suggestive of SS, including diaphoresis, tachycardia, hypertension, agitation, insomnia, incoordination, hypertonia (lower limbs >> upper limbs), and hallucinations. Serum creatine phosphokinase levels reached a peak on day 3 (2,577 U/L, reference value <145), suggesting mild rhabdomyolysis. No relevant changes were detected in other laboratory examinations or in the electrocardiogram throughout the period of hospitalization. The quantification of sibutramine and the active metabolites, M1 (mono-desmethyl sibutramine) and M2 (di-desmethyl sibutramine), by liquid chromatography/electrospray ionization tandem mass spectrometry in six sequential samples collected from 25 to 147 h post-ingestion revealed a nonlinear decrease in the log-scale plasma concentrations. Treatment was only supportive and involved prolonged sedation to control the agitation, sleeplessness, and hypertension; no cyproheptadine was used. The patient was discharged on day 6 and follow-up revealed no sequelae. CONCLUSION: To our knowledge, this is the first report of SS after sibutramine overdose in a child, with sequential monitoring of the plasma levels of the drug and its two active metabolites. The growing consumption of weight reducing pills may increase the risk of unintentional acute toxic exposures in children.

Chinese slimming capsules containing sibutramine sold over the Internet: a case series.

BACKGROUND: In recent years, the market for dietary supplements has grown. International products are readily available for purchase over the Internet. We report 17 cases of poisoning with a single product, said to be of purely herbal origin, that was bought over the Internet. A complete declaration of the ingredients was not available. METHODS: We performed a retrospective study of cases of poisoning documented by the Göttingen and Freiburg poison information centers from 2005 to 2008. In 4 cases, we were able to perform toxicological analyses of leftover capsules and urine samples. RESULTS: The manifestations of poisoning in the 17 documented cases included malaise, tachycardia, headache, agitation, arterial hypertension, nausea, vomiting, dyspnea, insomnia, left-sided chest pressure, elevated temperature, and, in two cases, psychosis after the substance was combined with atomoxetine and methylphenidate and with citalopram, olanzapine, and chlorprothixene. The frequency of cases rose markedly in the last year of the study. The toxicological analyses of all samples studied revealed sibutramine. The dose in each capsule was nearly twice the maximum daily dose sibutramine in the medication containing this substance that is licensed for use in Germany. CONCLUSIONS: Products available without a prescription whose contents are claimed to be purely herbal may nonetheless contain synthetic substances in concentrations far above the therapeutic range and may be a cause of poisoning. When taking the history of a patient possibly suffering from an intoxication, the physician should ask specifically about drugs, dietary supplements, and so-called lifestyle products that were obtained without a prescription. It would be desirable for the contents of all such products to be declared, as required by law, so that their suitability for the market can be checked.

A survey of moniliformin contamination in rice and corn from Keshan disease endemic and non-KSD areas in China.

Keshan Disease (KSD) is an endemic heart disease and moniliformin (MF) has been suggested as one of the etiological factors. In this paper, thin layer chromatographic (TLC) and high pressure liquid chromatographic (HPLC) methods were used for the determination of MF in the rice and corn samples collected from KSD areas and non-KSD areas. One hundred and twenty-three rice samples were analyzed and showed MF contamination in only 8 samples (KSD areas: 8.4% positive; non-KSD areas: 2.5% positive) ranging from 73.6 to 265.3 ng/g (mean concentration: KSD areas 156.3 ng/g; non-KSD areas 179.5 ng/g). One hundred and four corn samples in KSD areas and non-KSD areas were determinated by HPLC method, 45.2% samples were contaminated with MF (KSD areas: 81.4%; non-KSD areas: 19.7%) ranging from 52.3 to 1116.0 ng/g (mean concentration: KSD areas 488.9 ng/g; non-KSD areas 457.4 ng/g). The results showed that the contamination of MF in grains were significantly different between rice and corn, but not between the grains from the KSD areas and non-KSD areas, then casting doubt on the role of MF as an etiological factor of KS.

Effects of feeding Fusarium fujikuroi culture material, containing known levels of moniliformin, in young broiler chicks.

An experiment was conducted with 270 male broiler chicks to evaluate the effects of a Fusarium fujikuroi M-1214 culture material containing moniliformin (M) on broiler chicks. Day-old chicks were allotted randomly to dietary treatments containing 0, .24, .48, .72, .96, 1.44, 1.92, 2.40, and 2.88% M culture material (MCM). These levels of MCM supplied 0, 25, 50, 75, 100, 150, 200, 250, or 300 mg M/kg of feed. Each dietary treatment was fed to six pen replicates of five chicks per pen for 21 d. Significant mortality (P < .05) occurred in chicks fed 200 (8 out of 30), 250 (17 out of 30), and 300 (25 out of 30) mg M/kg feed. Chicks fed > 100 mg M/kg had lower (P < .05) feed intakes and smaller BW gains (P < .05) than controls. Increased heart weights (P < .05) were observed in chicks fed > 50 mg M/kg, and increased liver weights (P < .05) in chicks fed > 100 mg M/kg. Gross lesions of M toxicity included generalized cardiomegaly with dilation of the right ventricle. Histopathology revealed a high incidence of large and variably shaped cardiomyocyte nuclei and a generalized loss of cardiomyocyte cross striations in chicks fed > 75 and 200 mg M/kg, respectively. Results indicated that F. fujikuroi culture material containing M is toxic to young broiler chicks.

Toxicity of Fusarium moniliforme var. subglutinans for chicks, ducklings, and turkey poults.

Corn-based diets contaminated with various concentrations of a moniliformin-producing isolate of Fusarium moniliforme var. subglutinans were found to be lethal for chicks, ducklings, and turkey poults. Ducklings appeared to be the most sensitive to the lethal effects of the toxic feed. Gross lesions were ascites, hydropericardium, and myocardial pallor. Microscopic lesions were limited to the heart and liver, and they consisted of degeneration and necrosis of the myocardium and degeneration of hepatocytes. Cardiotoxicosis was the apparent cause of death.