A Fatal Case of Bupropion Overdose

Abstract Introduction: Bupropion is an aminoketone antidepressant that functions as a norepinephrine-dopamine reuptake inhibitor and FDA approved for the treatment of major depressive disorder, seasonal affective disorder and smoking cessation. While therapeutic dosing of bupropion may result in nonspecific adverse drug effects (ADEs) such as dry mouth, constipation, headaches, nausea, the more concerning life-threatening sequelae of bupropion overdose in the form of neurotoxicity (seizures and status epilepticus) and cardiotoxicity (arrhythmias and cardiogenic shock) resulting in fatality is rare. Hence, we report an unfortunately fatal case of a 48-year-old woman who succumbed to bupropion overdose secondary to cardiotoxigenic non sustained ventricular tachycardia, QRS interval prolongation and subsequent cardiogenic shock in the setting of intentional self-harm. Case Report A 48-year-old woman with of past medical history anxiety, depression and alcohol use disorder presented lethargic to the emergency department (ED) for bupropion overdose after reportedly ingesting 15-20 Bupropion 300mg tablets and unknown propranolol with Vodka with a witness 45-second seizure that resolved without intervention. The patient was subsequently intubated and sedated for airway protection. Initial investigation revealed bupropion level of 1436 ng/mL, elevated lactate of 4.1 mmol/L, positive amphetamine metabolites on toxicology screen and arterial blood gas consistent with metabolic acidosis. EKG (Fig 1) revealed Right Bundle Branch Block (RBBB), left anterior fascicular block with prolonged QRS of 170ms. Telemonitor showed multiple runs of non sustained ventricular tachycardia. Bedside echo demonstrated depressed left ventricular function. Intravenous sodium bicarbonate and lidocaine were given, and norepinephrine was initiated for hypotension. Poison control was consulted, and the patient was urgently transferred to a tertiary institution with considerations for ECMO. However, Do Not Resuscitate (DNR) measures were instituted. The patient's blood pressure continued to downtrend despite escalating pressor requirement and she passed away within 12 hours of first medical contact. Discussion Although Bupropion overdose poses a unique health crisis given the sheer number of 16,926 cases of overdose reported by the American Association of Poison Control in 2020, only eight fatalities were attributed to overdose making fatality a rare occurrence, thereby giving credence to this case report as a vital addition to bupropion toxicity discussion. This case serves as a reminder to always exercise extreme caution in making early predictions regarding outcome even though a vast majority overdose cases are nonfatal. Role of VA ECMO in poison patient is with severe cardiogenic shock is still unclear and need to be studied well. Fig: EKG in the ED.