(Kiosk 1) Spinal Cord Injury Secondary to Serotonin Syndrome: A Case Report

Case Diagnosis: Spinal Cord Injury secondary to Serotonin Syndrome

Case Description or Program Description: A 22-year-old female with a past medical history of migraines, syncope, labile blood pressures, bipolar disorder, supraventricular tachycardia, anorexia nervosa, and seizures, presented status post syncopal episodes with lower extremity paraparesis. She was evaluated and treated at Mayo clinic for autonomic dysfunction and acute paraparesis. However, she failed a myriad of therapies. A pacemaker was implanted and she was diagnosed with serotonin syndrome secondary to antipsychotic medications. Despite medical changes, her lower limb paraparesis was unchanged. Diagnostic tests ruled out pheochromocytoma and other coagulopathies. The patient was graded Asia C for T12 Incomplete Spinal Cord Injury.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: The patient's initial neurological examination was follows: 1/5 bilateral dorsiflexion, 0/5 bilateral hip flexion and knee extension, 4-/5 strength left elbow flexible and extension, and 5/ 5 strength right elbow flexion and extension. In therapy, she first participated in sit to stand trails requiring partial assistance of two therapist with contact guard assistance and cues for foot placement/balance. Patient proceeded to strengthen gait with Electrical stimulation and was eventually able to tolerate 10 min in the standing frame while engaging with Therex.

Discussion (relevance): There are many etiologies of non-traumatic myelopathy, metabolic causes being one of them. Serotonin syndrome can cause prominent lower extremity neuropathic abnormalities such as tremor, myoclonus, hyperreflexia, and bilateral Babinski sign. Other observed clinical features, in chronic cases, include stiffness of the limbs (43%), gait disturbances (36%), bowel disturbances (36%), incoordination (14%), and fatigue (14%) which are similar to spinal cord injury.

Conclusions: There are various documented etiologies of non-traumatic spinal cord injury cases. Serotonin syndrome needs to be included as a differential diagnosis for non-traumatic spinal cord injury, as it can lead to significant lower limb paraparesis. Early therapy intervention with appropriate medical management can lead to modest outcomes.