Reactions 1513, p14-15 - 9 Aug 2014

O SClomipramine overdose

Cardiac arrest and rhabdomyolysis: case reportA 55-year-old woman developed cardiac arrest and

rhabdomyolysis following a massive overdose ofclomipramine; subsequently she died.

The woman, who had a history of depression treated withclomipramine and fluoxetine, was admitted into theemergency room after ingesting 120 pills of clomipramine25mg in a suicide attempt 2 days before admission. Eighty pillswere removed by gastric lavage a few hours after ingestion. Onadmission, she was awake, but disoriented, reported drymouth and tremors at the extremities. ECG revealed sinusrhythm with narrow QRS complexes. On admission, testsrevealed an elevated creatine phosphokinase (CK) with15094 U/L, hypocalcaemia, a slight increase in serumtransaminase and mild metabolic acidosis. On the day ofadmission, she had cardiac arrest with pulseless electricactivity for 7 minutes.

The woman was treated with advanced cardiac life supportand received sodium bicarbonate. She showed spontaneouscirculation with sinus bradycardia and narrow QRS complexes,which were treated with atropine. On the next day, aftersedation she was only responsive to painful stimuli. Shereceived benzodiazepines for stopping the tremors at theextremities and in the lips. Two days after cardiac arrest, acranial CT showed brain swelling, without cerebellar tonsilherniation. One week after ingestion, her CK level decreasedto 385 U/L. A chest X-ray showed alveolar opacity in the lowerright hemithorax and in the left hemithorax, and also diffusebronchi and low PaO2/FiO2 ratio. She was treated withceftriaxone and clindamycin. She also developed refractoryhypotension which was treated with vasopressors. The cranialCT scan was repeated 48 hours after the first one and nochanges were noted. Neurological progenesis wasunfavourable due to anoxic brain damage and, two monthslater, she died [cause of death not stated].

Author comment: "Although arrhythmia is the mostimportant complication, rhabdomyolysis should beinvestigated in cases of clomipramine poisoning." "The casereported here forms an example of the range ofclomipramine toxicity, and highlights an extremely rarecomplication: rhabdomyolysis."Santana NO, et al. Rhabdomyolysis as a manifestation of clomipramine poisoning.Sao Paulo Medical Journal 131: 432-5, No. 6, 2013. Available from: URL: http://dx.doi.org/10.1590/1516-3180.2013.1316541 - Brazil 803106577

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Reactions 9 Aug 2014 No. 15130114-9954/14/1513-0001/$14.95 Adis © 2014 Springer International Publishing AG. All rights reserved