Bupropion extended-release overdose leading to sustained ventricular tachycardia and cardiogenic shock

SESSION TITLE: Unusual Complications of Known Side Effects of Drugs SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/11/2023 09:40 am - 10:25 am INTRODUCTION: Bupropion is a commonly used antidepressant and because of this is number one cause of intoxication induced seizures. (1) However, what is unique to bupropion is its ability to induce cardiogenic shock as compared to other antidepressants. (1,2) Cardiogenic shock occurs for multiple pharmacologic reasons. First, bupropion acts on the gap junctions of cardiac muscle leading to blocking of cardiomyocytes cell to cell signaling. This leads to prolongation of QRS and dramatic reduction in systolic function. (1,2) Secondly, it blocks potassium channels leading to increased QTc intervals which can lead to refractory ventricular arrhythmias. (1,2) In our case a 35-year-old female intentionally ingested 30 tables of the extended-release bupropion leading to cardiogenic shock. CASE PRESENTATION: 35-year-old female with past medical hx of depression presented to the ER reporting that she took 30 tables of bupropion. Shortly after presentation she had two sequential seizures. Both required benzodiazepines with easy breaking and patient arousable. However, shortly after she became hypotensive and was unarousable requiring intubation for airway protection and transfer to the medical intensive care unit (MICU). Upon arrival patient had worsening of vasopressor requirements, dilated fixed pupils, and no brain stem reflexes. Toxicology advised patient to have whole bowel lavage to clear remaining medication. However, she was determined to have ileus at this point and was unsafe to be performed, leaving the remaining medications in her system slowly releasing. She then began to have doubling of her vasopressors with bedside ultrasound showing severe reduction in her cardiac function. She then went into a wide complex ventricular tachycardia that was refractory to amiodarone. She self-converted with ECMO team contacted and plan for possible cannulation. During this time, she had multiple episodes of seizure like activity with EEG showing no actual activity, indicating possible myoclonus seizure mimicking activity. However, with aggressive diuresis and medical support she was able to be weaned down off vasopressors over the next 36 hours and no returns of arrhythmias. She was able to be extubated during this time and made a successful recovery. DISCUSSION: Bupropion toxicity is a unique toxicity as it mimics brain death. The high levels of bupropion lead to complete shut down of the brain with iso electric EEG and lack of brainstem reflexes. (3) Non-epileptic myoclonus jerking that can occur prior to seizures and even after intubation. (3,4). This was seen in our patient with EEG showing no active seizure likely activity and even persisted as mentation improved. Bupropion blocking the cardiac potassium channels and gap junctions lead to severe cardiogenic shock and refractory VT and cardiogenic shock. (1,2) Given this rapid recognition is needed as VA-ECMO cannulation may be the only possible option for these patients. CONCLUSIONS: Bupropion toxicity can lead to refractory cardiogenic shock as well as seizures. Early recognition with initiation of activated charcoal and whole gut irritation are imperative. Refractory cardiogenic shock may be unamendable to typical therapies and require early VA ECMO cannulation. Our patient ultimately was able to recover due to early intervention based off point of care ultrasound findings. REFERENCE #1: 1. Thundiyil JG, Kearney TE, Olson KR. Evolving epidemiology of drug-induced seizures reported to a Poison Control Center System. J Med Toxicol. 2007 Mar;3(1):15-9. doi: 10.1007/BF03161033. PMID: 18072153; PMCID: PMC3550124. REFERENCE #2: 2. Morazin F, Lumbroso A, Harry P, Blaise M, Turcant A, Montravers P, Gauzit R. Cardiogenic shock and status epilepticus after massive bupropion overdose. Clin Toxicol (Phila). 2007 Oct-Nov;45(7):794-7. doi: 10.1080/15563650701665076. PMID: 17924251. REFERENCE #3: 3. Stranges D, Lucerna A, Espinosa J, Malik N, Mongeau M, Schiers K, Shah SO, Wiley J, Willsie P. A Lazarus effect: A case report of Bupropion overdose mimicking brain death. World J Emerg Med. 2018;9(1):67-69. doi: 10.5847/wjem.j.1920-8642.2018.01.011. PMID: 29290899; PMCID: PMC5717380.4. Xiang XM, Phillips DJ. Nonepileptic Myoclonus Following Bupropion Overdose. Clinical Pediatrics. 2018;57(9):1100-1102. doi:10.1177/0009922817737082 DISCLOSURES: No relevant relationships by Matthew Ballenberger No relevant relationships by Brenda Garcia No disclosure on file for Jane Jacob No relevant relationships by Zein Kattih No relevant relationships by Priyanka Makkar No relevant relationships by Simon Meredith No relevant relationships by Jacob Schwartz No relevant relationships by Kevin Shayani