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Background
Over the counter (OTC) drug abuse and dependence has recently emerged as a significant global health concern, leading to a surge in emergency room cases of acute intoxication [1]. Dextromethorphan (DXM), a commonly used cough suppressant that elevates serotonin levels, has gained popularity for its euphoric hallucinogenic properties in recreational abuse, particularly among young individuals [2, 3].
High-dose DXM ingestion is known to trigger serotonin syndrome, which is characterized by psychiatric, neuromuscular, and autonomic symptoms. In severe cases, serotonin syndrome may progress to rhabdomyolysis, acute kidney injury (AKI), and even death [4]. While this condition is often associated with the use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, DXM monotherapy has also been implicated as a potential cause [5].
To the best of our knowledge, there have been no reported cases of severe DXM-induced serotonin syndrome requiring dialysis for rhabdomyolysis and AKI. Given the severity of this condition, this case highlights the importance of awareness in both clinical practice and public health. Herein, we present this case to contribute to the understanding and potentially life-threatening complications of DXM abuse.
Case presentation
A Japanese man in his 20s was admitted to our hospital for altered mental status. He had a 1-year history of depression but had discontinued psychotherapy at a psychiatric clinic. Laboratory examination 4 months prior showed a serum creatinine (Cr) level of 0.7 mg/dL. In addition, 2 months before admission, he began purchasing and taking DXM for recreational use from a legally operated online pharmacy. He was not taking any other medications, including antidepressants or illegal substances. He had poor oral intake for several days prior to admission. On the day of admission, he became severely agitated after consuming approximately 1800 mg of DXM, prompting his father to seek emergency medical attention.
Upon arrival, the patient presented with diaphoresis, hyperthermia (38.9 °C), tachycardia (135 beats per minute), hypertension (153/93 mmHg), and tachypnea (oxygen saturation of 96% on 5 L of oxygen per min), with a Glasgow Coma Scale score of 11 (E4V2M5). Physical examination revealed profuse sweating, ocular clonus, and muscle rigidity in the extremities. Laboratory testing exhibited a serum Cr level of 2.3 mg/dL, creatine kinase (CK) level of 78,659 U/L, serum myoglobin level of 3495 ng/mL, and urinary myoglobin...