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Multiple Complications and Withdrawal Syndrome Associated with Quetiapine/Venlafaxine Intoxication

Clinical Pharmacist, Department of Pharmacy Services, Hôpital Ste-Justine, Montréal, Québec, Canada

Magdalena Dunewicz, MD

Emergency Physician, Department of Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec

Geneviève Grégoire, MD

Intensivist, Department of Intensive Care Medicine, Hôpital du Sacré-Coeur de Montréal; Assistant Professor of Medicine, Faculté de Médecine, Université de Montréal, Montréal

David R Williamson, MSc (Pharm) BCPS

Clinical Pharmacist, Department of Pharmacy Services, Hôpital du Sacré-Coeur de Montréal; Clinical Assistant Professor, Faculté de Pharmacie, Université de Montréal

Reprints: Mr. Williamson, Hôpital du Sacré-Coeur de Montréal, 5400, Boul. Gouin Ouest, Montréal, Québec H4J 1C5, Canada, fax 514/338-3200, david.williamson{at}umontreal.ca

OBJECTIVE: To report a case of quetiapine/venlafaxine intoxication associated with multiple complications and to review their possible relationship with these 2 drugs.

CASE SUMMARY: A 53-year-old white man was admitted to the hospital for loss of consciousness secondary to voluntary intoxication with venlafaxine and quetiapine. Several complications were attributable to this intoxication including seizures, prolonged coma, respiratory depression, neuroleptic malignant syndrome, prolonged QRS and QTc intervals, and a possible venlafaxine withdrawal syndrome.

DISCUSSION: Quetiapine could be responsible for the neuroleptic malignant syndrome presented in this case. Moreover, venlafaxine intoxication, fever, autonomic instability, and myoclonus presented serotonin syndrome as a differential diagnosis. Potential causes of seizures and prolongation of the QRS and QTc intervals are reviewed. Finally, prolonged coma and late venlafaxine withdrawal are discussed with regard to the pharmacodynamics and pharmacokinetics of drug elimination in the context of intoxication.

CONCLUSIONS: Clinicians should be aware of possible complications following intoxication with atypical antipsychotics and anti-depressants, including protracted altered mental status.

Key Words: neuroleptic malignant syndrome, quetiapine, venlafaxine

Published Online, November 23, 2004. www.theannals.com, DOI 10.1345/aph.1E073

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