Delayed Serotonin Syndrome and Non-cardiogenic Pulmonary Edema Following Bupropion Overdose in a Seven-Year-Old Female: A Case Report and Review of Literature

Abstract

Bupropion is an atypical antidepressant prescribed for depression and attention-deficit/hyperactivity disorder and to aid in smoking cessation. Bupropion overdose management is largely aimed toward common sequelae, including seizures, tachycardia, and QTc prolongation. In this case report, we identify a rare event of pediatric bupropion overdose with aforementioned common sequela and atypical features, including a delayed presentation of serotonin syndrome and non-cardiogenic pulmonary edema. This case follows a seven-year-old Caucasian female with autism spectrum disorder (ASD) who presented in status epilepticus following an accidental bupropion overdose and required multiple anti-seizure medications, endotracheal intubation, and admission to the pediatric intensive care unit (PICU). The patient's condition improved, and she was extubated 25 hours after admission and transitioned to high-flow nasal cannula therapy. On day 3 of admission, she became febrile and developed dyspnea with decreased breath sounds and intercostal retractions, tachycardia, a rigid abdomen and extremities with sporadic tremors, pulmonary edema, and a prolonged QTc interval. Targeted therapies were initiated, and following treatment, our patient showed remarkable improvement in the subsequent 24 hours and was discharged home five days after the initial presentation. This case identifies a delayed presentation of uncommon and serious complications of bupropion overdose, including pulmonary edema and serotonin syndrome, in a pediatric patient. Prompt investigation and identification of bupropion toxicity can help practitioners mitigate further complications during admission and reduce morbidity and mortality.

Keywords: bupropion overdose; non-cardiogenic pulmonary edema; prolonged qtc interval; serotonin toxicity; status epilepticus (se).

Figure 1. The chest X-ray taken after ET placement upon admission.

ET: endotracheal tube

Figure 2. The patient's EKG at admission.

EKG: electrocardiogram

Figure 3. A pill bottle found in the patient's home.

Figure 4. The patient's chest X-ray on day 2 of admission.

Figure 5. The patient's EKG showed prolonged QTc on day 3 of admission.

EKG: electrocardiogram

Figure 6. The patient's chest X-ray showed signs concerning for pulmonary edema.

Figure 7. The patient's chest X-ray 10 hours later following BiPAP showed resolving pulmonary edema.