Objective:

To describe a case of massive bupropion toxicity leading to myoclonic seizures, burst suppression, loss of brainstem reflexes and cardiac arrest requiring VA-ECMO and LVAD support with subsequent complete neurological and cardiac recovery. 

Background:

Bupropion is an atypical antidepressant and norepinephrine–dopamine reuptake inhibitor prescribed for major depressive disorder, seasonal affective disorder and smoking cessation. Overdose can cause severe neurological and cardiovascular complications. Massive ingestion can transiently mimic brain death, complicating prognostication and management decisions.

Design/Methods:

Not Applicable

Results:

We describe a 25-year-old female with a history of anxiety, depression, and prior suicide attempt who ingested a 60-day supply of bupropion 300 mg extended-release. She presented with myoclonic status epilepticus requiring intubation and sedation. On neurological examination off of sedation, she exhibited absent pupillary, corneal, gag, and cough reflexes, as well as absent vestibulo-ocular reflexes and no motor response to painful stimuli. Continuous EEG demonstrated bursts of 5–7 Hz generalized spike-and-wave discharges with background suppression. The patient subsequently developed pulseless electrical activity arrest and achieved return of spontaneous circulation after 45 minutes. She required VA-ECMO and LVAD support for cardiogenic shock. Both cardiac support devices were successfully removed after five days. She achieved full neurological recovery and was eventually weaned off antiseizure medication following a normal routine EEG with no epileptiform activity or seizure recurrence.

Conclusions:

Massive bupropion overdose can mimic brain death with reversible severe neurocardiac dysfunction. Premature neuroprognostication should be avoided. Early consideration for ECMO support may improve outcomes in severe cases.