(1165) Drowning From Wellbutrin: Severe ARDS From Bupropion-Mediated Cytokine Storm

Introduction: Bupropion is a commonly prescribed antidepressant often implicated in suicide attempts. Sequelae of overdose include QTc prolongation, seizures and rarely flash pulmonary edema. Acute Respiratory Distress Syndrome (ARDS) as a delayed complication has not been established.

Description: A 29-year-old lady with a history of depression presented to the ED by EMS for a reported intentional bupropion overdose of 1100mg. On arrival, she was tachycardic, hypotensive, and minimally responsive. She was intubated and placed on mechanical ventilation for airway protection. Appropriate sedation was initiated. She received supportive care in the intensive care unit and was extubated the next day in stable condition on 4L oxygen nasal cannula. The next morning she experienced new-onset hypoxia and severe cyanosis quickly worsening on BiPAP therapy. Chest x-ray showed new pulmonary edema and left lower lobe opacity concerning for mucous plug. The decision was made to emergently re-intubate for impending respiratory arrest. This was complicated by an aspiration event. Despite mechanical ventilation on 100% FiO2 and 20 of PEEP, arterial blood gas analysis showed PaO2 49 mmHg. PaO2 to FiO2 ratio was 49 with repeat chest x-ray exhibiting diffuse bilateral airspace opacities consistent with severe ARDS. Emergent bronchoscopy was unremarkable for mucous plugging. Echocardiogram ruled out heart failure. She was deemed a candidate for Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) due to persistent hypoxemia and transferred to another facility for higher level of care. The patient was extubated after 7 days and decannulated from VV-ECMO a day later and remained stable from a hemodynamic and respiratory perspective. She was eventually discharged home in stable condition on room air with appropriate medical and psychiatric follow up.

Discussion: Bupropion is a known cause of increased proinflammatory cytokines including Interleukin (IL) 4,5, 7, 8, 10. ARDS is associated with widespread cytokine release, specifically IL 6, 8, and 10, sometimes referred to as cytokine storm, leading to lung injury. It is postulated that bupropion at higher doses drives increased cytokine synthesis leading to development of proinflammatory states and delayed secondary lung injury, manifesting as ARDS as described above.