Key message
This study aims to demonstrate some of the adverse effects related to sumatriptan toxicity; a drug is used to treat migraine. Other studies are required to reveal these side effects, especially for patients with underlying diseases such as chronic kidney disease.
Introduction
One of the most prevalent and socioeconomically impactful disabling primary headache is migraine, and its acute daily attacks can be treated by prescription of sumatriptan orally or subcutaneously (1, 2).
This potent drug acts on 5-HT1 receptors, leading to vasoconstriction. Like other medications, it has side effects like tachycardia, transient hypertension, behavioral instability, facial edema, angle-closure glaucoma, cardiac arrhythmias, abdominal pain, bloody diarrhea because of vascular ischemia, splenic infarction, hepatotoxicity, and Raynaud’s syndrome (3-6).
Previously, Owen et al. revealed side effects of sumatriptan poisoning in rodents and dogs. Moreover, Mobasheran et al. demonstrated renal injury by activating nitric oxide synthase in rats induced by sumatriptan, but there is no available information in humans (3, 5, 7). This case report presents a case with sumatriptan poisoning who had complications including nephritic syndrome.
Case Presentation
In February 2022, a 20-year-old bodybuilder man presented to the emergency department with unusual sweating, agitation, hallucination, and urine and fecal incontinency. He was admitted to the toxicology ward due to the injection of 30 vials of sumatriptan (each vial is 6milligram/0.5milliliter solution) 2 days before his admission. He had no complaints, such as respiratory difficulties or chest pain.
Past medical and habitual history for any drug or substances were negative. At admitted time, vital signs demonstrated high blood pressure (150/90 millimeter of mercury) and tachycardia (126 per minute). On the other hand, respiratory rate (18 per minute), temperature (37.1° Celsius,) and oxygen saturation (99%) were normal. Moreover, the initial Glasgow coma scale (GCS) was 15/15.
According to the protocol, primary conservative treatment was started for this patient. After a few hours, he became unconscious (GCS=9/15) and was intubated.
Laboratory findings displayed hypernatremia and increased creatinine, liver function markers, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), and D-dimer level. Qualitative measurement of cardiac biomarkers such as troponin was also positive in this patient. Besides, hematuria (3+) and proteinuria (2+) were detected in the urine analysis but his urine drug test was negative for morphine, tramadol, methadone, and tetrahydrocannabinol, amphetamine, and methamphetamine. Laboratory tests are described in Table1.
Additionally, normal sinus rhythm was detected in his electrocardiogram (ECG). Full cardiac monitoring and serial ECG and troponin were performed for him because of positive troponin. Computed tomography (CT) angiography was requested because pulmonary embolism (PE) was suspected but was not performed due to hemodynamic instability. In order to high suspicion, treatment for PE was started as soon as possible. Despite advanced medical treatment, the cardiopulmonary arrest happened after six days.
At autopsy, the lungs were dilated with purulent discharge, and a normal-sized heart was observed with no apparent stenosis in coronary arteries and no fibrosis and hyperemia in myocardial sections. Besides, abnormalities were not found in the liver, spleen, or kidneys. Cerebral edema due to hypoxia was detected in the brain with normal consistency. Moreover, post mortem toxicological assessment had no scientific value due to more than 6 days of hospitalization.
Consequently, hypernatremia, positive troponin, elevated level of creatinine, liver enzymes, CPK and LDH, hematuria, and proteinuria were associated with sumatriptan poisoning.