A Fatal Case of Moclobemide-Citalopram Intoxication

To the Editor: We would like to comment on the article "A Fatal Case of Serotonin Syndrome after Combined Moclobemide-Citalopram Intoxication " (1). The authors describe the postmortem determination f moclobemide and citalopram using a newly developed analytic technique. However, the conclusion that he patient they describe died from serotonin syndrome is not supported by conclusive clinical or toxicological evidence. Serotonin toxicity is characterised by a triad of clinical features: (1)autonomic features; (2) neuromuscular changes; and (3) altered mental status (2). Sternbach's criteria, the most commonly cited for the diagnosis (3), are based on clinical findings in patients taking agents that cause increased levels of serotonin i the central nervous sy tem. Thus, being a clinical diagnosis, serotonin syndrome cannot be diagnosed postmortem, although itmay be suspected, based on the presence of serotonergic agents in postmortem toxicological analyses. The authors ' description ofserotonin toxicity includes features not typically regarded as p rt of the syndrome, for example, generalized tonic-clonic convulsions (3), although myoclonic spasms and hypertonia may be mistaken for seizure activity. Some selective serotonin reuptake inhibitors, such as citalopram, and the selective serotonin and noradrenaline r uptake inhibitor venlafaxine are associated wi h seizures in overdose, apart from causing serotonin toxicity (4,5). Blood pressure lability is more characteristic ofneuroleptic malignant syndrome (2). Although patients may ultimately die from cardiac arrest in severe cases