{
  "abstract": "Situation A 15 year old girl (F) was admitted to a Paediatric Intensive Care Unit (PICU) following one week history of headache, dizziness and neck pain, culminating in 48hours of profuse vomiting and eventual collapse. On arrival at a District General Hospital she was hypotensive, hypoglycaemic and hypothermic with metabolic acidosis and Acute Kidney Injury (AKI). She was resuscitated with fluids and inotropes, and started CVVHDF (Continuous Veno-Venous Haemodiafiltration). Initial head computed tomography scan (CT) and toxicology screen were normal. Inflammatory markers were raised. She had one episode of fast atrial fibrillation requiring an amiodarone loading dose. During a lumbar puncture, saturations dropped, she became flaccid and required intubation. F was transferred to PICU at a tertiary childrens’ hospital for ongoing management. Sertraline was stopped because F was nil by mouth. Past medical history included Autism Spectrum Disorder and anxiety. F was on melatonin and high dose sertraline.Sertraline related MADD (Multiple Acyl Co-enzyme A Dehydrogenase Deficiency, also known as glutaric aciduria Type 2) was diagnosed on Day 9 of PICU admission, based on abnormal amino-acid profile, lab reported vitamin deficiencies and timing of symptoms in relation to recent increased sertraline dose.1 2 Riboflavin, thiamine and levocarnitine were added on advice of metabolic team, and vitamin D, vitamin B12, folic acid and iron were supplemented based on blood results.F received intensive pharmacy input from a dedicated PICU team (including a Clinical Pharmacy Technician) at every stage of her admission, from reviewing doses due to AKI and subsequent recovery of renal function, recommending dose adjustments due to high body weight, advising on vitamin dosing as her working diagnosis changed, consulting on a complex sedation regime throughout her admission and liaising with many specialist teams. Our pharmacist prescribers worked as an integral part of the PICU team to make adjustments to F’s medicines throughout her stay. Our Medicines Information department were instrumental in providing information on incidence and treatment of this MADD-like illness. F improved slowly over a four week period, and was discharged to ward with residual symptoms after 30 days in PICU.Lessons Learned Prevalence of MADD is estimated to be in 1/200,000 to 250,000. In the neonatal forms, a genetic cause is usually found. In late-onset MADD (childhood to adulthood), symptoms are usually milder but highly variable. The most common symptom is muscle weakness, and a clear genotype-phenotype correlation is lacking. 3 There are limited case reports of patients with late-onset MADD, no identified genotype, and taking sertraline.1 2 Treatment consists of withdrawal of sertraline. These reports recommended starting riboflavin with some also using levocarnitine and/or co-enzyme Q10, similar to the treatment of MADD itself.3 4 Occurrence of MADD-like illness related to sertraline is rare, and is partly a diagnosis of exclusion due to lack of firm diagnostic criteria. Our patient demonstrated the importance of a multi-disciplinary approach to investigation of complex illnesses – F was reviewed by almost every specialty team within a tertiary paediatric centre before a tentative diagnosis was made.References Multiple acyl-Coenzyme a dehydrogenase deficiency is associated with sertraline use - is there an acquired form? Ann Neurol 2024;96(4):802–811.Watson-Fargie T, Coomber A, Edwards R, et al. Late-onset multiple-acyl-CoA-dehydrogenase deficiency-like condition: a case series from the West of Scotland. Neuromuscular Disord. 2025;49:no pagination. doi:10.1016/j.nmd.2025.105343.Prasun P. Multiple Acyl-CoA Dehydrogenase Deficiency. 2020 Jun 18. In: Adam MP, Feldman J, Mirzaa GM, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993–2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558236/British Inherited Metabolic Diseases Group. BIMDG Formularies [Internet]. 2024 [cited 2025 Jun 24]. Available from: Formularies - BIMDG",
  "authors": [
    {
      "affiliations": [
        "NHS Greater Glasgow And Clyde, UK"
      ],
      "name": "Nicola Wilson"
    },
    {
      "affiliations": [
        "NHS Greater Glasgow And Clyde, UK"
      ],
      "name": "Jennifer Kimmins"
    },
    {
      "affiliations": [
        "NHS Greater Glasgow And Clyde, UK"
      ],
      "name": "Andrew Stockton"
    }
  ],
  "title": "P09 Are you MADD? A case report of sertraline induced MADD-like illness",
  "uid": "872b4b5c-89c9-51cb-8eb8-f3bd3776d1ba"
}