Document Detail

Linezolid is associated with serotonin syndrome in a patient receiving amitriptyline, and fentanyl: a case report and review of the literature.
Jump to Full Text
MedLine Citation:
PMID:  23533900     Owner:  NLM     Status:  PubMed-not-MEDLINE    
We report a unique case of an adverse interaction between the oxazolidinone antibiotic linezolid, the tricyclic antidepressant amitriptyline and the opioid analgesic fentanyl in a 68-year-old woman with advanced ischemic peripheral arterial disease and sepsis, under empirical antibiotic treatment. We also summarize the current relevant literature as identified via PubMed, EMBASE, and PsycINFO as well as reference sections of selected articles.
Lampros Samartzis; Paraskevi Savvari; Sofoklis Kontogiannis; Stavros Dimopoulos
Publication Detail:
Type:  Journal Article     Date:  2013-03-04
Journal Detail:
Title:  Case reports in psychiatry     Volume:  2013     ISSN:  2090-682X     ISO Abbreviation:  Case Rep Psychiatry     Publication Date:  2013  
Date Detail:
Created Date:  2013-03-27     Completed Date:  2013-03-28     Revised Date:  2013-03-29    
Medline Journal Info:
Nlm Unique ID:  101583308     Medline TA:  Case Rep Psychiatry     Country:  United States    
Other Details:
Languages:  eng     Pagination:  617251     Citation Subset:  -    
Department of Psychiatry, Mental Health Services, Athalassa Psychiatric Hospital, 1452 Nicosia, Cyprus.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Case Rep Psychiatry
Journal ID (iso-abbrev): Case Rep Psychiatry
Journal ID (publisher-id): CRIM.PSYCHIATRY
ISSN: 2090-682X
ISSN: 2090-6838
Publisher: Hindawi Publishing Corporation
Article Information
Download PDF
Copyright © 2013 Lampros Samartzis et al.
Received Day: 21 Month: 1 Year: 2013
Accepted Day: 6 Month: 2 Year: 2013
Print publication date: Year: 2013
Electronic publication date: Day: 4 Month: 3 Year: 2013
Volume: 2013E-location ID: 617251
PubMed Id: 23533900
ID: 3603624
DOI: 10.1155/2013/617251

Linezolid Is Associated with Serotonin Syndrome in a Patient Receiving Amitriptyline, and Fentanyl: A Case Report and Review of the Literature
Lampros Samartzis1 0000-0002-4380-3036
Paraskevi Savvari2
Sofoklis Kontogiannis2
Stavros Dimopoulos2* 0000-0003-2199-3788
1Department of Psychiatry, Mental Health Services, Athalassa Psychiatric Hospital, 1452 Nicosia, Cyprus
2Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, 80 Vas. Sofias Avenue, 11528 Athens, Greece
Correspondence: *Stavros Dimopoulos:
[other] Academic Editors: J. S. Brar and D. E. Dietrich

1. Case

Ms. B, a 68-year-old woman, presented at our outpatient clinic with intense lower foot pain and fever since a week. Clinical examination revealed the 3 first phalanges of the left foot painful, cyanotic, and swollen in the absence of palpable pulsus at the ventral and dorsal tibial arteries with concomitant fever (38.5°C) and tachycardia (110 bpm). A complete blood count showed elevated total number of white blood cells (21 × 109/L), consisted of 93% from neutrophil granulocytes. She was admitted to our hospital due to sepsis and possible diagnosis of infection of the ischemic left foot. Anamnestic history included advanced peripheral ischemic disease, diabetes mellitus type II, arterial hypertension, and major depression. The patient was receiving treatment with fentanyl transdermal patch 25 μg/h every 72 h since 10 days and amitriptyline 25 mg BD for depression. The low dose of amitriptyline 25 mg BD was maintained due to its antidepressant [1, 2] as well as analgesic effects on chronic pain [35] and especially painful diabetic limb [612]. During her stay in the medical ward, she was treated with empirical antibiotics including cloxacillin, 3rd generation beta-lactams, and aminoglycosides with an initial general improvement. However, at the 10th day patient had a new onset of high fever (38.7°C) and linezolid 600 mg every 12 hours was added to the treatment regimen and cloxacillin was stopped. Within the first 24 hours of antibiotic change treatment, the patient had a rapid clinical deterioration manifesting symptomatology of restlessness, diaphoresis, tremor, shivering, myoclonus, and high fever (40°C), as well as gradual mental status disorders with disorientation, confusion, and coma. The patient was intubated due to severe respiratory difficulties according to the criteria of our clinic, and transferred to the intensive care unit. Brain computerized tomography and lumbar puncture (LP) for the exclusion of central neural system (CNS) infection were unremarkable. The constellation of the above neurological and mental state features in the presence of serotonergic medication [1315] and the abstinence of other CNS pathology leads to the diagnosis of serotonin syndrome according to the diagnostic criteria of Hunter [16, 17] and Sternbach [14]. The first signs of improvement appeared a few hours after the interruption of linezolid and amitriptyline. Withdrawal of sedation and ventilator weaning took place 48 hours later. The patient gradually regained her consciousness and orientation to person, location, and time, as expected in the opposite order in which she lost orientation in the beginning of the confusion state [18].

Amitriptyline is a tricyclic antidepressant (TCA), a drug category that is believed to act through boosting of serotonin and norepinephrine neurotransmission via blockade of serotonin and norepinephrine reuptake pumps [19], as well as via desensitizing both 5-HT1A and beta-adrenergic receptors. Tertiary amineTCAs, such asamitriptyline, imipramine, and clomipramine, are more potent inhibitors of serotonin reuptake than secondary amine TCAs, such as nortriptyline or desipramine, therefore theoretically more prone to be involved in the development of serotonin syndrome.

Fentanyl is an synthetic opioid analgesic, which is characterised by high lipid solubility and therefore it easily penetrates the central nervous system (CNS), where it acts through binding to μ-opioid receptors (mu receptors) resulting in inhibition of pain neurotransmission [2022]. Fentanyl belongs to the phenylpiperidine subcategory of opioid substances, as do methadone, pethidine (meperidine), tramadol, propoxyphene, and dextromethorphan. Phenylpiperidine opioids are considered to have mild serotonin-reuptake inhibition (SRI) properties and therefore a higher possibility, for involvement in serotonin syndrome development [23]. The nonphenylpiperidine opioids, such as buprenorphine, codeine, morphine, and oxycodone, were not reported to show SRI properties [24]. Interestingly, there is a report of paradoxical reaction regarding fentanyl use in the treatment of serotonin syndrome [25], which had been induced by coadministration of the selective serotonin reuptake inhibitor (SSRI) fluoxetine and the reversible inhibitor of monoamine oxidase A (MAO-A) moclobemide.

Linezolid is an oxazolidinone category antibiotic that is believed to act through early inhibition of protein synthesis via binding to the 23S portion of the 50S ribosomal bacterial rRNA subunit [26, 27] inducing conformational structural changes and preventing tRNA to enter and functionally bind to the ribosome [28] therefore inhibiting mRNA translation. Linezolid is a totally synthetic compound that was initially synthesized as a reversible MAO inhibitor class antidepressant [29].

Serotonin syndrome usually consisted of a constellation of neurological and mental state symptoms and commonly diagnosed according to the widely accepted criteria of Sternbach and/or Hunter [14, 16, 17, 30], as summarised in Table 1. Symptoms usually improve with the withdrawal of the predisposing drug agents plus supportive care, as there is no specific evidence-based treatment of the syndrome [31]. Cyproheptadine is a H1 histamine receptor antagonist as well as a nonspecific serotonin receptor antagonist [32] which may have a role in serotonin syndrome treatment in a usual dose of 8 mg via the nasogastric tube.

The development of the serotonin syndrome has been reported as an interaction of linezolid plus almost every category of antidepressant medication. Interactions have been found with the selective serotonin reuptake inhibitors (SSRIs) as citalopram [29, 3339], escitalopram [34], paroxetine [40], fluoxetine [41, 42], sertraline [4345], with tryptophan, a precursor of serotonin [46], with noradrenaline and specific serotonergic agents (NaSSA) as mirtazapine [29], with serotonin 2 antagonist/reuptake inhibitor (SARI) as trazodone [36], the azapirone category anxiolytic buspirone that is a serotonin 1A partial agonist and serotonin stabilizer [47], the dual serotonin and noradrenaline reuptake inhibitors (SNRIs) as the antidepressants venlafaxine [36, 4851] and duloxetine [52], and the tricyclic antidepressant (TCA) imipramine [49]. Although amitriptyline [14, 5356] and fentanyl [5764] have been both involved in serotonin syndrome, no case has been reported involving their combination.

To the knowledge of the authors, this is the first case of serotonin syndrome reported in a patient receiving this common three-drug combination.

Fentanyl is primarily metabolized via CYP-P450-3A4 isoenzyme system by oxidative dealkylation to the main metabolite norfentanyl which is inactive [65].

Amitriptyline is metabolised via CYP-P450-1A2 isoenzyme by demethylation to form the active metabolite nortriptyline [66] and via CYP-P450-2D6 by hydroxylation to form inactive metabolites [19], but there is also data showing that demethylation via CYP-P450-3A4 plays an important role in its metabolism [6769]. Therefore a pharmacokinetic interaction between fentanyl and amitriptyline could not be excluded. Nevertheless, in our case, coadministration of amitriptyline and fentanyl did not reveal any symptomatic interaction, as the serotonin syndrome was induced only after the addition of linezolid to the treatment regimen.

Linezolide is metabolised via oxidation procedure in a way independent of cytochrome P450 (CYP-450); consequently there is no possible pharmacokinetic mechanism of interaction between linezolide and other medication metabolized through CYP450 pathways [27].

Also, the serotonin syndrome pathophysiological mechanism does not include idiosyncratic, neither idiopathic nor pharmacokinetic drug reactions, but it is considered to be a predictable and preventable pharmacodynamic consequence of the excess of serotonergic agonism in CNS and peripheral serotonergic receptors [17].

We suggest that physicians avoid use of linezolid in patients receiving combination of amitriptyline and fentanyl due to possible serotonin syndrome induction.

1. Guaiana G,Barbui C,Hotopf M. Amitriptyline for depressionCochrane Database of Systematic ReviewsYear: 200732-s2.0-35348922807CD004186
2. Barbui C,Hotopf M. Amitriptyline v. the rest: still the leading antidepressant after 40 years of randomised controlled trialsBritish Journal of PsychiatryYear: 20011781291442-s2.0-003513725311157426
3. Lynch ME. Antidepressants as analgesics: a review of randomized controlled trialsJournal of Psychiatry and NeuroscienceYear: 200126130362-s2.0-003512065611212591
4. Sawynok J,Esser MJ,Reid AR. Antidepressants as analgesics: an overview of central and peripheral mechanisms of actionJournal of Psychiatry and NeuroscienceYear: 200126121292-s2.0-003512076111212590
5. Botney M,Fields JL. Amitriptyline potentiates morphine analgesia by a direct action on the central nervous systemAnnals of NeurologyYear: 19831321601642-s2.0-00206806806219612
6. Bryson HM,Wilde MI. Amitriptyline. A review of its pharmacological properties and therapeutic use in chronic pain statesDrugs and AgingYear: 1996864594762-s2.0-00298972468736630
7. Bril V. Treatments for diabetic neuropathyJournal of the Peripheral Nervous SystemYear: 201217supplement 2222722548619
8. Bril V,England J,Franklin GM,et al. Evidence-based guideline: treatment of painful diabetic neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and RehabilitationPhysical Medicine and RehabilitationYear: 201134345e1352e212-s2.0-79954564711
9. Cayley WE Jr.. Antidepressants for the treatment of neuropathic painAmerican Family PhysicianYear: 20067311193319362-s2.0-3374494894216770921
10. Joss JD. Tricyclic antidepressant use in diabetic neuropathyAnnals of PharmacotherapyYear: 199933999610002-s2.0-003286369210492505
11. Kopsky DJ,Keppel Hesselink JM. High doses of topical amitriptyline in nuropathic pain: two cases and literature reviewPain PractYear: 20121214815321676162
12. Max MB,Culnane M,Schafer SC. Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed moodNeurologyYear: 19873745895962-s2.0-00231550572436092
13. Taylor D,Paton C,Kapur S. The Maudsley Prescribing Guidelines in PsychiatryYear: 2012Cornwall, UKWiley
14. Sternbach H. The serotonin syndromeAmerican Journal of PsychiatryYear: 199114867057132-s2.0-00258697972035713
15. Shameen M,Taylor D. Serotonin syndromePsychiatric BulletinYear: 199923742747
16. Dunkley EJC,Isbister GK,Sibbritt D,Dawson AH,Whyte IM. The hunter serotonin toxicity criteria: simple and accurate diagnostic decision rules for serotonin toxicityQJMYear: 20039696356422-s2.0-004237740312925718
17. Boyer EW,Shannon M. Current concepts: the serotonin syndromeNew England Journal of MedicineYear: 200535211111211202-s2.0-1504436169815784664
18. Casey PR,Kelly B. Fish’s Clinical Psychopathology: Signs and Symptoms in PsychiatryYear: 2007Glasgow, UKRoyal College of Psychiatrists
19. Stahl SM. Essential Psychopharmacology, Neuroscientific Basis and Practical ApplicationsYear: 20083rd editionNew York, NY, USACambridge University Press
20. Imai S,Narita M,Ozeki A,et al. Difference in tolerance to anti-hyperalgesic effect and its molecular mechanisms between chronic treatment with morphine, fentanyl and oxycodone in a chronic pain-like stateNihon Shinkei Seishin Yakurigaku ZasshiYear: 2008285-61691762-s2.0-5804910988019108502
21. Muijsers RBR,Wagstaff AJ. Transdermal fentanyl: an updated review of its pharmacological properties and therapeutic efficacy in chronic cancer pain controlDrugsYear: 20016115228923072-s2.0-003569565311772140
22. Subramanian G,Ferguson DM. Conformational landscape of selective μ-opioid agonists in gas phase and in aqueous solution: the fentanyl seriesDrug Design and DiscoveryYear: 200017155672-s2.0-003408831510928449
23. Codd EE,Shank RP,Schupsky JJ,Raffa RB. Serotonin and norepinephrine uptake inhibiting activity of centrally acting analgesics: structural determinants and role in antinociceptionJournal of Pharmacology and Experimental TherapeuticsYear: 19952743126312702-s2.0-00290482677562497
24. Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicityBritish Journal of AnaesthesiaYear: 20059544344412-s2.0-2644451115116051647
25. Chambost M,Liron L,Peillon D,Combe C. Serotonin syndrome during fluoxetine intoxication in a patient using moclobemideCanadian Journal of AnesthesiaYear: 20004732462502-s2.0-003362470610730736
26. Paladino JA. Linezolid: an oxazolidinone antimicrobial agentAmerican Journal of Health-System PharmacyYear: 20025924241324252-s2.0-003711531612503340
27. Fung HB,Kirschenbaum HL,Ojofeitimi BO. Linezolid: an oxazolidinone antimicrobial agentClinical TherapeuticsYear: 20012333563912-s2.0-003529320611318073
28. Wilson DN,Schluenzen F,Harms JM,Starosta AL,Connell SR,Fucini P. The oxazolidinone antibiotics perturb the ribosomal peptidyl-transferase center and effect tRNA positioningProceedings of the National Academy of Sciences of the United States of AmericaYear: 20081053613339133442-s2.0-5164911709918757750
29. DeBellis RJ,Schaefer OP,Liquori M,Volturo GA. Linezolid-associated serotonin syndrome after concomitant treatment with citalopram and mirtazepine in a critically ill bone marrow transplant recipientJournal of Intensive Care MedicineYear: 20052063513532-s2.0-3364484511116280409
30. Taylor JJ,Wilson JW,Estes LL. Linezolid and serotonergic drug interactions: a retrospective surveyClinical Infectious DiseasesYear: 20064321801872-s2.0-3374572838116779744
31. Perry PJ,Wilborn CA. Serotonin syndrome vs neuroleptic malignant syndrome: a contrast of causes, diagnoses, and managementAnnals of Clinical PsychiatryYear: 201224215516222563571
32. Graudins A,Stearman A,Chan B,Kulig K. Treatment of the serotonin syndrome with cyproheptadineJournal of Emergency MedicineYear: 19981646156192-s2.0-00321269289696181
33. McClean M,Walsh JC,Condon F. Serotonin syndrome in an orthopaedic patient secondary to linezolid therapy for MRSA infectionIrish Journal of Medical ScienceYear: 201118012852862-s2.0-7995443783720886306
34. Lorenz RA,Vandenberg AM,Canepa EA. Serotonergic antidepressants and linezolid: a retrospective chart review and presentation of casesInternational Journal of Psychiatry in MedicineYear: 200838181902-s2.0-5064910531818624020
35. Go AC,Golightly LK,Barber GR,Barron MA. Linezolid interaction with serotonin reuptake inhibitors: report of two cases and incidence assessmentDrug Metabolism and Drug InteractionsYear: 201025141472-s2.0-7995148805821417793
36. Bergeron L,Boulé M,Perreault S. Serotonin toxicity associated with concomitant use of linezolidAnnals of PharmacotherapyYear: 20053959569612-s2.0-1764438335015827071
37. Bernard L,Stern R,Lew D,Hoffmeyer P. Serotonin syndrome after concomitant treatment with linezolid and citalopramClinical Infectious DiseasesYear: 2003369p. 11972-s2.0-0038556783
38. Tahir N. Serotonin syndrome as a consequence of drug-resistant infections: an interaction between linezolid and citalopramJournal of the American Medical Directors AssociationYear: 2004521111132-s2.0-164240864114984623
39. Hachem RY,Hicks K,Huen A,Raad I. Myelosuppression and serotonin syndrome associated with concurrent use of linezolid and selective serotonin reuptake inhibitors in bone marrow transplant recipientsClinical Infectious DiseasesYear: 2003371e8112-s2.0-034727600112830431
40. Wigen CL,Goetz MB. Serotonin syndrome and linezolidClinical Infectious DiseasesYear: 20023412165116522-s2.0-003709765312032904
41. Steinberg M,Morin AK. Mild serotonin syndrome associated with concurrent linezolid and fluoxetineAmerican Journal of Health-System PharmacyYear: 200764159622-s2.0-3394712598217189581
42. Thomas CR,Rosenberg M,Blythe V,Meyer WJ. Serotonin syndrome and linezolidJournal of the American Academy of Child and Adolescent PsychiatryYear: 2004437p. 7902-s2.0-3042607958
43. Lavery S,Ravi H,McDaniel WW,Pushkin YR. Linezolid and serotonin syndromePsychosomaticsYear: 20014254324342-s2.0-003476645211739912
44. Sahiner V,Erden Aki SO. Serotonin syndrome associated with linezolid use: a case reportTürk Psikiyatri DergisiYear: 20092043984022-s2.0-7795163279120013432
45. Clark DB,Andrus MR,Byrd DC. Drug interactions between linezolid and selective serotonin reuptake inhibitors: case report involving sertraline and review of the literaturePharmacotherapyYear: 20062622692762-s2.0-3204444363316466332
46. Colomar Ferrá A,Ventayol Bosch P,Raurich JM. Serotonin syndrome due to interaction between linezolid, tryptophan, and metoclopramideMedicina IntensivaYear: 20093373603612-s2.0-7034941769519828401
47. Morrison EK,Rowe AS. Probable drug-drug interaction leading to serotonin syndrome in a patient treated with concomitant buspirone and linezolid in the setting of therapeutic hypothermiaInternational Journal of Clinical Pharmacology and TherapeuticsYear: 2012375610613
48. Mason LW,Randhawa KS,Carpenter EC. Serotonin toxicity as a consequence of linezolid use in revision hip arthroplastyOrthopedicsYear: 20083111p. 11402-s2.0-65349130712
49. Miller DG,Lovell EO. Antibiotic-induced serotonin syndromeJournal of Emergency MedicineYear: 201140125272-s2.0-7865110768218455905
50. Packer S,Berman SA. Serotonin syndrome precipitated by the monoamine oxidase inhibitor linezolidAmerican Journal of PsychiatryYear: 200716423463472-s2.0-3384725785117267801
51. Jones SL,Athan E,O’Brien D. Serotonin syndrome due to co-administration of linezolid and venlafaxineJournal of Antimicrobial ChemotherapyYear: 20045412892902-s2.0-354306010815140859
52. Strouse TB,Kerrihard TN,Forscher CA,Zakowski P. Serotonin syndrome precipitated by linezolid in a medically ill patient on duloxetineJournal of Clinical PsychopharmacologyYear: 20062666816832-s2.0-3375109281817110838
53. Bodner RA,Lynch T,Lewis L,Kahn D. Serotonin syndromeNeurologyYear: 19954522192237854515
54. Lane R,Baldwin D. Selective serotonin reuptake inhibitor-induced serotonin syndrome: reviewJournal of Clinical PsychopharmacologyYear: 19971732082212-s2.0-00309849959169967
55. Nisijima K,Shimizu M,Abe T,Ishiguro T. A case of serotonin syndrome induced by concomitant treatment with low-dose trazodone and amitriptyline and lithiumInternational Clinical PsychopharmacologyYear: 19961142892902-s2.0-00304803599031998
56. Perry NK. Venlafaxine-induced serotonin syndrome with relapse following amitriptylinePostgraduate Medical JournalYear: 2000768942542562-s2.0-003410387110727586
57. Ailawadhi S,Sung KW,Carlson LA,Baer MR. Serotonin syndrome caused by interaction between citalopram and fentanylJournal of Clinical Pharmacy and TherapeuticsYear: 20073221992022-s2.0-3394741232017381671
58. Alkhatib AA,Peterson KA,Tuteja AK. Serotonin syndrome as a complication of fentanyl sedation during esophagogastroduodenoscopyDigestive Diseases and SciencesYear: 20105512152162-s2.0-7404913992319165596
59. Giese SY,Neborsky R. Serotonin syndrome: potential consequences of Meridia combined with Demerol or FentanylPlastic and Reconstructive SurgeryYear: 200110712932942-s2.0-003517119511176649
60. Gollapudy S,Kumar V,Dhamee MS. A case of serotonin syndrome precipitated by fentanyl and ondansetron in a patient receiving paroxetine, duloxetine, and bupropionJournal of Clinical AnesthesiaYear: 201224325125222537574
61. Kirschner R,Donovan JW. Serotonin syndrome precipitated by fentanyl during procedural sedationJournal of Emergency MedicineYear: 20103844774802-s2.0-7795166777318757161
62. Ozkardesler S,Gurpinar T,Akan M,et al. A possible perianesthetic serotonin syndrome related to intrathecal fentanylJournal of Clinical AnesthesiaYear: 20082021431452-s2.0-4184911671818410872
63. Reich M,Lefebvre-Kuntz D. Serotoninergic antidepressants and opiate analgesics: a sometimes-painful association. A case reportEncephaleYear: 201036supplement 2D119D1232-s2.0-7795302264820513454
64. Rastogi R,Swarm RA,Patel TA. Case scenario: opioid association with serotonin syndrome: implications to the practitionersAnesthesiologyYear: 201111561291129822037635
65. Feierman DE,Lasker JM. Metabolism of fentanyl, a synthetic opioid analgesic, by human liver microsomes: role of CYP3A4Drug Metabolism and DispositionYear: 19962499329392-s2.0-00298138388886601
66. Stahl SM. Essential Psychopharmacology: the Prescriber’s GuideYear: 2009New York, NY, USACambridge University Press
67. Venkatakrishnan K,Greenblatt DJ,Von Moltke LL,Schmider J,Harmatz JS,Shader RI. Five distinct human cytochromes mediate amitriptyline N-demethylation in vitro: dominance of CYP 2C19 and 3A4Journal of Clinical PharmacologyYear: 19983821121212-s2.0-00319087449549641
68. Olesen OV,Linnet K. Metabolism of the tricyclic antidepressant amitriptyline by cDNA-expressed human cytochrome P450 enzymesPharmacologyYear: 19975552352432-s2.0-00307357339399333
69. Ghahramani P,Ellis SW,Lennard MS,Ramsay LE,Tucker GT. Cytochromes P450 mediating the N-demethylation of amitriptylineBritish Journal of Clinical PharmacologyYear: 19974321371442-s2.0-00310583429131945

Article Categories:
  • Case Report

Previous Document:  Left sided oesophageal lung: a diagnostic challenge.
Next Document:  Pulmonary embolism related to amisulpride treatment: a case report.