Serotonin syndrome and rhabdomyolysis induced by concomitant use of triptans, fluoxetine and hypericum

We describe a 28-year-old woman affected by migraine without aura according to the ICHD-2 criteria who manifested with seizures as presenting symptom of a serotonin syndrome characterized by mild and transient fever and subtle postural hand tremor. Few days later she developed an acute rhabdomyolysis with associated increased D-dimer and liver enzymes. The condition was precipitated by triptans use. Chronic therapy with fluoxetine, taken to treat an eating disorder, and the use of a self-prescribed herbal medication containing hypericum predisposed to a serotonergic hyperstimulation. This case report calls attention on the importance to avoid multidrug regimens for the prevention of serotonin syndrome that can present with atypical symptoms and may worsen with severe acute rhabdomyolysis.