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The authors report the case of an eleven-month old infant who was given maprotiline and clobazam. He was found in coma state and suffered from convulsions, that were treated with phenobarbital. The electrocardiogram showed a right bundle branch block and a left anterior hemiblock over 72 h. The child then recovered without sequelae.

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A 6-year-old girl presented with tonic-clonic seizures and generalized convulsions lasting several minutes. A serum drug screen revealed maprotiline, and the estimated intake was 12 mg/kg. Despite initial neurologic impairment on discharge, follow-up 6 months later showed normal neurologic function in the patient. This report describes that case and discusses the toxicity associated with maprotiline and its management.

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Chart review of all patients admitted over a six-month period to the University of Missouri-Columbia Medical Intensive Care Unit after intentional drug overdose revealed that the drugs ingested today are quite different from those used five to 20 years ago. I selected for review cases representative of overdose with three of the more commonly used drugs--acetaminophen, ethylene glycol, and tricyclic antidepressants.

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To compare the relative central nervous system and cardiac toxicity of amoxapine, maprotiline, and trazodone with the older tricyclic antidepressants, a three-year (1981 through 1983) retrospective review was performed on 1,313 cases involving cyclic antidepressant exposures reported to the Maryland Poison Center. Seizures were more common in the amoxapine (24.5%) and maprotiline (12.2%) groups, compared with either the tricyclic antidepressants (3.0%) or trazodone (0%) (P less than .01). A higher incidence of seizures also was observed in desipramine ingestors (17.9%) compared with other tricyclic antidepressants. No significant differences in the incidence of central nervous system depression or cardiotoxicity was found between the groups. These findings support reports of an increased incidence of seizures in overdoses of amoxapine and maprotiline, but do not substantiate claims of less cardiotoxicity.

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A case is reported of self-poisoning with maprotiline followed by prolonged disorders of intraventricular conduction. The cardiotoxicity of tetracyclic antidepressants was well established, but few cases were reported. Maprotiline pharmacokinetics explained the duration of the cardiovascular side-effects. The severity of maprotiline overdoses should not be underestimated.

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A fatal maprotiline intoxication is presented. The postmortem anatomical and toxicologic findings are discussed, as is the mechanism of maprotiline toxicity. This report is, to the best of our knowledge, the sixth fatal maprotiline poisoning in the medical literature.

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Maprotiline is a tetracyclic drug with effects similar to those of tricyclic antidepressants. It has been suggested that tetracyclic antidepressants have fewer cardiovascular side-effects. We describe a case with serious alteration of intraventricular conduction after maprotiline overdosage.

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We report a fatal case of drug toxicity associated with torsade de pointes following an overdose of the tetracyclic antidepressant, maprotiline (Ludiomil). Tissue and plasma levels were obtained at autopsy and are noted. In addition, the cardiovascular effects, pharmacokinetics, and toxicity of maprotiline are reviewed and compared with that of tricyclic antidepressants.

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A 64-year-old man ingested 4500 mg of maprotiline hydrochloride. He developed major motor myoclonic seizures, first-degree AV block, intraventricular conduction delay, hypotension, and urinary retention. Myoclonic seizures have not been previously reported with maprotiline toxicity.

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Maprotiline, a new tetracyclic antidepressant, has a pattern of toxicity that is different from that of tricyclics. Maprotiline overdosage appears more likely to cause seizures but less likely to cause the peripheral autonomic and cardiac manifestations seen with tricyclics. Two cases of maprotiline overdose resulting in seizures without significant anticholinergic or cardiotoxic effects are presented. Both patients were treated acutely with gastric emptying and were observed to have no further seizures during subsequent drug-free hospital and outpatient follow up. Physostigmine salicylate has been used as an antidote for the anticholinergic syndrome of tricyclic overdose, but probably offers less in maprotiline overdose. Careful observation for seizures appears to be warranted.

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Self poisoning with maprotiline was studied in 41 patients (43 episodes) consecutively admitted to an intensive care unit. Thirty five patients had taken more than one drug or alcohol. Fifteen patients were in coma grade III or IV; 17 patients were still not conscious after 24 hours in the intensive care unit. Among six patients given ventilation the mean duration of ventilation in the five who recovered was 36 hours. Three patients had a cardiorespiratory arrest, and one patient died. Twenty eight patients had a QRS interval of 100 ms or more, and 15 patients had seizures. In six patients seizures were precipitated by physostigmine. Cardiotoxicity after overdosage of maprotiline is equal to if not greater than that found after overdosage of conventional tricyclic antidepressants. Overdosage of maprotiline is more often associated with seizures than overdosage with tricyclic antidepressants. Physostigmine further increases the risk of seizures and should not be used in cases of overdosage of maprotiline.

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From 1975 to 1982, the Austrian Poison Information Centre gave medical advice in forty cases of acute melitracenee-flupenthixol poisoning. The case reports were reviewed and analysed in retrospect. 13 patients who either had ingested less than 20 pills (n = 5) or who underwent early gastric lavage (n = 8) showed no symptoms. In 19 patients who had swallowed 20 to 60 (n = 11), 60 to 100 (n = 3) pills respectively, or an unknown dose (n = 5) atropine like symptoms predominated. Five patients developed atropine like and extrapyramidal symptoms. The number of pills taken by these patients ranged from 20 to 60 (n = 4) and in one up to 100. Extrapyramidal reactions were encountered as predominant symptoms in three patients one of which had taken 20, the other 60 and the third an unknown number of pills. Additionally, five patients were unconscious. 21 patients developed ECG changes, 19 of which showing sinus tachycardia. The remaining two patients who had ingested 600 to 1000 mg melitracen atrial premature beats or T-wave inversions were observed. All 40 patients recovered.

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A new tetracyclic antidepressant drug, maprotiline hydrochloride was found to be the agent of death in a 23-year-old subject following massive injestion (4.5-6.0 g). The case may be the first reported maprotiline death (sole cause) in the United States. Analytical parameters were studies and various chromatographic and spectrophotometric systems are reported. Quantitation was performed by gas-liquid chromatography using a nitrogen-phosphorous detector. Concentrations of the compound in biological fluids and tissues are also reported.

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