I am working on a forensic case with a psychiatrist regarding a man we evaluated in a psychiatric evaluation who developed complex partial seizures due to clandestine lab exposure, specifically lithium and methamphetamine labs, throughout his career working as a police officer. We reviewed his current list of medications, and he is taking 50 mg of sertraline (Zoloft) once per day.
The research that I found shows that higher doses of sertraline increases the risk of seizure, including partial complex, and that sertraline and methylphenidate (a CNS stimulant) can precipitate seizures. Though, I'm trying to eliminate variables here... 50 mg qd of sertraline is an ordinary prescription. Were the lithium and/or meth vapors interacting with his sertraline, or is there another reason why he was experiencing seizures?
Hi !
Sertraline is not supposed to do seizure at therapeutical doses , as 50 mg a day...Moreover, it is supposed to be a "good choice" for epileptic people that suffer from depression... Article Antidepressants in epilepsy
Methamphet, as any stimulant , can induce seizure, but the incidence is low...Article Chapter Seven. Neurologic Complications of Psychomotor Stimulant Abuse
=> Did you think about the potential exposure to solvants or any volatil hydracarbure used for the synthesis in these labs... Maybe they could induce neuronal damages ?
"Lithium may enhance the pharmacologic effects of selective serotonin reuptake inhibitors (SSRIs) and potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. The exact mechanism by which lithium increases serotonergic activity is unknown. The interaction has been reported with fluoxetine and fluvoxamine and the serotonin-norepinephrine reuptake inhibitor venlafaxine. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea. Conversely, SSRIs may elevate the plasma concentrations of lithium and increase the risk of lithium toxicity. The interaction has been associated with fluoxetine, while citalopram and paroxetine reportedly do not cause the interaction. Excessive somnolence has been reported with lithium and fluvoxamine"
https://www.drugs.com/drug-interactions/lithium-with-zoloft-1477-0-2057-1348.html?professional=1
Stavros Keritsis : It is important to precise the kinetic for seizures : Is it during the first hours (between 6h and 24h) post exposure ? or are you talking about seizures that occur many month or year after ?
Marie Humbert-Claude S. Béatrice Marianne Ewalds-Kvist Thank you for the answers and literature! Will ask more questions with more later when needed.
Another consideration when taking zoloft and other selective serotonin reuptake inhibitors (SSRIs) is whether the person was eating foods that happen to be high in serotonin, such as bananas, walnuts, and wheat pasta. Eating copious amounts of these foods can be associated with symptoms of serotonin excess, such as tachycardia (rapid heart rate) or constant palpitations (pounding heartbeat) leading to serotonin syndrome.
Ruling out other considerations might be the following from different sources:
- Lights Some people with epilepsy have mentioned that they get a seizure when they are in an environment with flashy or strong lights, like strobe lights. Lights can be a causing factor for tonic clonic, absence, or myoclonic seizures. The condition is known as photosensitive epilepsy. The patients can have a seizure due to activities that might not be fatal for other people, like watching TV for a long time, playing video games, or riding/driving in broad daylight with spaced trees allowing the sunlight to pass through gaps. This can create a flashing light effect and can be a causing factor for a seizure in people with photosensitive seizure. In some cases, the patient can have a seizure even due to blinking their own eye; however, this accounts for only 3% of all the cases.
- There are some activities that can trigger a seizure, keep away from them especially when you are undergoing treatment for a seizure. Avoid going to places that have flashing lights, like pubs or clubs. Watching a movie in the theatres can also trigger your seizure. If your children are going through treatment for seizures, keep them away from video games. The flashy lights and the geometric designs of a video game can trigger a seizure, but only in rare cases.
- Sleeping is very important for you to keep the seizure away, ensure that you get enough rest on a regular basis. Do not change your sleep schedule very often. Get enough sleep, set a routine, and stick to it.
- A seizure can also be caused by stress or tension. If you are going through a stressful situation, you must practice some relaxation and stress management techniques. Along with relaxation, also go ahead with some breathing techniques.
- Watching TV in a dark room for a long time or watching a film at the theatre can be troublesome for you. Working on the computer for extended hours should be avoided. If you are going to work, make sure you take timely breaks that help your situation.
- Avoid the use of drugs and alcohol, in any case. As mentioned above, you must not indulge in any activities if you are using drugs or alcohol. Along with this, you must follow a healthy diet pattern so that you are healthier and your immune system is able to fight the condition better.
Insulinomas This symptom is associated with the formation of tumors that produce insulin. The main feature of insulin is to lower blood glucose levels in the body. An excessive amount of insulin in the body can lead to a significant drop in the blood sugar. When the blood sugar drops, it can lead to a person having seizures, fainting, or even going into a coma.
VIPomas The formation of these tumors in the body leads to the production of vasoactive intestinal peptide (VIP). Increased amounts of VIP in the body can lead to medical conditions like diarrhea. The symptoms of diarrhea will begin weakly but will get stronger as the condition worsens. Other associated symptoms include nausea, muscle cramps, fatigue, flushing (warmth or redness in the facial and neck area), and vomiting. People with these tumors might have low levels of acid, which leads to a difficulty in the digestion of food.
Carcinoid tumors The primary product of these tumors is serotonin or its precursor, 5-HTP. When a tumor in the pancreas produces these substances, there is a high possibility of them traveling to the liver. The liver protects the body by breaking down these tumors, controlling them from reaching other parts of the body and causing problems. However, these tumors do make their way to other parts of the body. Due to the stoppage in the liver, these tumors do not cause any symptoms until they reach other parts of the body. These symptoms can go unnoticed as they occur in phases, between which a person might not feel affected.
temporal lobe epilepsy
Irrespective of the type of brain cancer, brain seizure is one of the most common symptoms that is noticed in patients with brain cancer. When the tumor in the brain comes in contact with the neurons, they start to shoot uncontrollably and cause an abnormal electrical disturbance in the brain, which is called a brain seizure. A brain cancer patient can experience different types of brain seizures, such as a whole-body seizure or a partial seizure which is limited to only a certain region of your body.
Dehydration can trigger epileptic seizures if it is severe enough. A number of disorders including: low blood sugar, low blood sodium, hyperosmolar nonketotic hyperglycemic state, https://en.wikipedia.org/wiki/Hyperosmolar_nonketotic_hyperglycemialycemia, high blood sodium, low blood calcium and high blood urea levels may cause seizures. As may hepatic encephalopathy (elevated ammonia) and the genetic disorder porphyria.
- Infection with the pork tapeworm, which can cause neurocysticercosis, is the cause of up to half of epilepsy cases in areas of the world where the parasite is common.[30]
- parasitic infections such as cerebral malaria. In Nigeria this is on of the most common causes of seizures among children under 5 years of age.[31]
- infection, such as encephalitis or meningitis[32]
Seizures may occur as a result of high blood pressure, known as hypertensive encephalopathy, or in pregnancy as eclampsia when accompanied by either seizures or a decreased level of consciousness.[18] Very high body temperatures may also be a cause.[18] Typically this requires a temperature greater than 42 °C (107.6 °F).[18]
- Head injury may cause non-epileptic post-traumatic seizures or post-traumatic epilepsy
- About 3.5 to 5.5% of people with celiac disease also have seizures.[36]
- Seizures in a person with a shunt may indicate failure
- Hemorrhagic stroke can occasionally present with seizures, embolic strokes generally do not (though epilepsy is a common later complication); cerebral venous sinus thrombosis, a rare type of stroke, is more likely to be accompanied by seizures than other types of stroke
- Multiple sclerosis may cause seizures
Firstly, a daily dose of 50 mg of sertraline seems a little low to me. I find that the usual dosing range is 100-200 (although I have prescribed higher). Saying that, I am not saying that it IS too low, but just seems a little lower.
I concur with the earlier points made SSRIs are associated with the lowering of the Sz threshold. Higher doses more so (suggesting that the lower dose is less likely to cause Sz). Saying that, seizures are often idiopathic. Did your subject sustain head injuries, were there other meds used or exposed to, and so forth. Has he had an EEG (is there a region of brain that is already electrically challenged)?
I apologize that I'm not really adding much to the discussion. I guess that I'm trying to say that I would be looking for other explanations of the partial, complex Szs.
Lawrence Berley Thanks for that information. Your keypoints brought up some stuff that I should have mentioned earlier.
In one particular instance, this individual, while on duty, was in pursuit of a criminal on foot in the woods. He chased him so hard to the point he overexerted himself and had to be taken to the hospital. This man also has a history of hypertension. In addition, he regularly ate fast food (typically junk food that is known to be high in sodium, white carbohydrates and bad fats) while on duty. He also has GI, vision and hearing problems probably from hypertension and on duty work (allegedly firing a pistol, police sirens—you did mention strobe lights, etc.)