We describe a case of an acute overdose in a former professional cyclist with a heavy past of doping and drug addiction. A 31-years-old man was admitted in hospital for generalized tonico-clonic seizures concomitant with hyperthermic syndrome and unstable hemodynamic status. During his transport to the emergency department, he presents two cardiopulmonary arrest, which required an external electric shock and adrenaline administration. History of the disease revealed that patient is in a context of benzodiazepines withdrawal. He complained for five days about shivers, sweats, headaches and nausea with change of his general state. Moreover, he would have taken cocaine at night previous his admission.

During his coverage by emergency service, the body temperature=40°C, SpO2=70%, blood pressure=70/40mmHg and heart rate=70/min. Several cardiac, biological and toxicological examinations were implemented during the hospitalization. Toxicology analysis was realized on blood. Blood screening was realized by LC-MS/MS, after liquid/liquid extraction in acidic and basic conditions. Specific methods were done for cocaine and tramadol quantification by LC-MS/MS, and for lidocaine by GC-MS. Other identified substances were quantified by LC-MS/MS or immunoassay analyses.

The electrocardiogram highlights conduction abnormalities (slow QT then ventricular extrasystoles). Biological examination revealed a mix severe acidosis (pH=7.27, paCO=6.64kPa, lactates=5.4mmol/L), an hypokaliemia (2.2mmol/L), and an acute kidney failure with creatinine at 169μmol/L associated with rhabdmyolyse (CPK=13,000U/L). Toxicological research revealed the presence in blood of high concentration of cocaine and its metabolites (cocaine concentration=290ng/mL, benzoylecgonine concentration=3000ng/mL). Moreover, several medicine drugs were also detected in blood sample (tramadol, acetaminophen, lidocaine and hydroxyzine). All are in therapeutic concentrations excepted tramadol, which was measured at the concentration of 1880ng/mL (and 2000ng/mL for O-DMT, its active metabolite).

This fatal overdose with a massive cocaine consumption associated with a large dose of tramadol presented a mixt adrenergic-serotoninergic syndrome with seizures, hyperthermia, blood pressure fluctuations, acidosis and hypokaliemia and rhabdomyolysis. Let us note that the high concentration of tramadol found in this case, has probably potentiate the toxic effect of cocaine. Interestingly, the main part of the toxic symptoms observed linked to tramadol seem rather in touch with the inhibition of the recapture of monoamine than with the opioid activity leading to mixt adrenergic-serotoninergic syndrome [1Malik H.U., Kumar K. Serotonin syndrome with escitolapram and concomitant use of cocaine: a case report Clin Med Insights Case Rep 2012 ;  5 : 81-85 [cross-ref]

Cliquez ici pour aller à la section Références]. This ascendancy of serotoninergic syndrome may be related with drug-abusing profile of the patient.