Abstracts

Rationale: Few cases have been reported of bupropion toxicity mimicking brain death. Even fewer reports have considered EEG findings of status epilepticus in this patient population. We report a unique case of bupropion overdose causing cardiogenic shock and myoclonic status epilepticus (MSE). While clinical exam was initially suggestive of brain death, the patient ultimately recovered with the use of extracorporeal membrane oxygenation (ECMO) and hemodialysis (HD).

Methods: Observation of a single case in an Academic center

Results: A 57-year-old female with history of major depressive disorder and prior suicide attempts presented following intentional overdose by ingestion of unknown substances. She was admitted to the critical care unit with cardiogenic shock, requiring multiple vasopressors. Neurology team was consulted for evaluation of witnessed clinical episodes of sustained rhythmic myoclonic activity. The patient exhibited absent brainstem reflexes and an overall clinical picture concerning for brain death. Given the complex clinical picture and rhythmic myoclonus, long-term monitoring with EEG was pursued.

The first nine hours of EEG recording was characterized by a burst suppression pattern, with the bursts consisting of generalized polyspike-and-wave discharges lasting up to eight seconds in duration. The bursts were accompanied by diffuse myoclonus, consistent with MSE (Figure 1). After the addition of levetiracetam, valproic acid, and midazolam infusion, the myoclonus resolved, however, the highly epileptiform burst suppression pattern continued. 

She later developed multiorgan failure, and ECMO and hemodialysis (HD) were initiated. Within 10 minutes of ECMO initiation, there was a complete resolution of the epileptiform discharges and the burst suppression pattern. This subsequently transitioned to a pattern of discontinuous generalized slowing with overriding beta frequencies (Figure 2). The recording became nearly continuous within an hour of ECMO initiation. 

Results of toxicology screen revealed hydroxybupropion level of 2596.1 ng/ml (Therapeutic range is 850-1500 ng/ml and Toxic level is >2000 ng/ml)

The patient made a full neurologic recovery and was discharged to an inpatient psychiatric unit.

Conclusions: Patients who present with drug overdose and clinical suspicion of brain death pose a challenge for treatment considerations. This case reflects the need for heightened suspicion of bupropion toxicity in patients presenting with cardiogenic shock, absent brainstem reflexes, cortical myoclonus, and burst-suppressed EEG. The decision to initiate ECMO and HD in this patient with a suicide attempt by bupropion overdose resulted in reversal of EEG and clinical abnormalities and was ultimately life-saving. Practitioners should heed caution prior to prognostication of brain death. Further studies are needed to analyze the effect of ECMO in patients with MSE in the setting of cardiogenic shock. To our knowledge, this is the only reported case of highly epileptiform burst suppression resolution with the initiation of ECMO.

Funding: None