title: Serotonin toxicity as a consequence of linezolid use in revision hip arthroplasty.
abstract: Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicrobial, it has activity against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, penicillin-resistant Streptococcus pneumoniae, and macrolide-resistant streptococci. There are several documented case reports of serotonin toxicity when used with selective serotonin reuptake inhibitors. The symptoms of serotonin syndrome are alteration of mental state, autonomic dysfunction, and neuromuscular disorders. This article presents a case of an interaction of the serotonin reuptake inhibitor venlafaxine and linezolid and the possible diagnostic problems that can occur. A 58-year-old woman presented with signs of systemic infection. Her medical history included bladder resection for transitional cell carcinoma, bilateral total hip arthroplasty (THA), and depression, for which she was on venlafaxine. Serological and imaging investigations revealed MRSA infection of the bilateral THA. The patient was started on vancomycin and rifampicin intravenously. As intravenous access was becoming problematic and long-term antibiotics were needed, treatment was changed to oral linezolid and oral rifampicin. Four days after the commencement of linezolid, the patient was acutely disorientated with generalized cerebellar signs and no autonomic dysfunction. A computed tomography scan of the head and lumbar puncture revealed no abnormal findings. A diagnosis of serotonin toxicity was made. The patient recovered when linezolid and venlafaxine were discontinued and supportive measures were provided. Linezolid is a popular choice of antibiotic, especially for the treatment of orthopedic-related MRSA infections. Patients who commonly require linezolid as an antimicrobial are those with complex infections where other antibiotic treatment has failed. It is therefore important to be vigilant with linezolid use. Physicians should be aware of the nonspecific presentation of serotonin symptoms and the treatment.
authors.affiliation: Department of Trauma and Orthopedic Surgery, University Hospital of Wales, Cardiff, Wales, United Kingdom.
authors.forename: Lyndon W
authors.initials: LW
authors.lastname: Mason
authors.forename: Kiran S
authors.initials: KS
authors.lastname: Randhawa
authors.forename: Eleanor C
authors.initials: EC
authors.lastname: Carpenter
mesh_terms: D000081:Acetamides / Q000009:adverse effects*; D000284:Administration, Oral; D000700:Analgesics / Q000009:adverse effects*; D000890:Anti-Infective Agents / Q000009:adverse effects*; D019644:Arthroplasty, Replacement, Hip; D000075202:Contraindications; D003511:Cyclohexanols / Q000009:adverse effects; D004347:Drug Interactions; D005260:Female; D006801:Humans; D000069349:Linezolid; D008875:Middle Aged; D023303:Oxazolidinones / Q000009:adverse effects*; D011183:Postoperative Complications; D012701:Serotonin / Q000378:metabolism*; D020230:Serotonin Syndrome / Q000139:chemically induced* / Q000378:metabolism / Q000503:physiopathology; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects; D000069470:Venlafaxine Hydrochloride
chemical_list: D000081:Acetamides; D000700:Analgesics; D000890:Anti-Infective Agents; D003511:Cyclohexanols; D000069349:Linezolid; D023303:Oxazolidinones; D012701:Serotonin; D017367:Selective Serotonin Reuptake Inhibitors; D000069470:Venlafaxine Hydrochloride