Reactions 1513, p15 - 9 Aug 2014

O SClomipramine overdose

Various toxicities: case reportA 41-year-old woman developed various toxicities due to

clomipramine overdose.The woman, who had a 10 year history of depression, was

discovered unconscious in her bathroom one morning. Emptypackets of her usual treatment were found at her homeincluding clomipramine 75mg tablets. The time and amountingested was not known. During the pre-hospital care, her BPwas 70/40 mmHg and her peripheral capillary oxygensaturation on room air was 90%. Her GCS score was 5 withintermediate, symmetrical and relatively non-reactive pupils.

The woman was intubated and received hydroxyethylstarch, sodium chloride, ephedrine, norepinephrine,midazolam and sufentanil. Upon admission to an ICU, shepresented with myoclonus and a reactive mydriasis. The initialclinical examination tended towards a central and peripheralanticholinergic toxidrome, consistent with clomipraminepoisoning. Despite therapy, her haemodynamic conditionremained unstable. She received dobutamine and charcoal. Achest X-ray showed the presence of radiopaque capsules in herstomach. Ten hours after initiation of the treatment, an ECGshowed widening of the QRS complexes, associated with anodal rhythm. She received sodium bicarbonate for theconduction alterations. Toxicological analysis revealedsignificantly increased clomipramine concentration at4489 µg/L, and a desmethylclomipramine concentration at378 µg/L. X-ray of her abdomen showed a conglomerate in thestomach consistent with a pharmacobezoar. An endoscopyrevealed large necrotic ulcers in the antrum of her stomach. Agastric lavage identified a mass of tablets at the large tuberosityand 35 whole tablets were removed. After 24 hours, another50 whole tablets were removed. Ten tablets could not beremoved due to their adherence to the mucosa. After the twoconsecutive endoscopies, the serum concentration of tricyclicantidepressants decreased. She awoke and her haemodynamiccondition stabilised. She was extubated 8 days after admissionand her serum concentrations of tricyclic antidepressantsreturned within normal limits; she was transferred to apsychiatric ward on day 15.

Author comment: "We report a case of pharmacobezoarformation due to acute clomipramine overdose."Durand G, et al. Pharmacobezoar in a clomipramine massive acute intoxication.Annales Francaises de Medecine d’Urgence 4: 181-186, No. 3, May 2014.Available from: URL: http://doi.org/10.1007/s13341-014-0429-z [French;summarised from a translation] - France 803106560

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