Table 2.

Timeline of development of symptoms and management

Time	Symptoms	Management
Day 1 8:33 a.m.	After taking SNRI, hot flush, stiffness around the neck and shoulder, diaphoresis, and muscle rigidity in the masseter appeared. BP 112/78 mmHg, 77 bpm, BT 37.4 °C	Body cooling Intravenous administration of dantrolene 40 mg for muscle rigidity. No abnormalities were found in the blood test.
10:10	No raise in serum serotonin level (4 ng/ml)	Diagnosed as serotonin syndrome Serotonergic agents (duloxetine and mirtazapine) were stopped immediately.
12:45	Myoclonus and tremor on the upper extremities. Tachycardia (120 bpm) and diaphoresis
13:00	Myoclonic seizures on the upper extremities and neck. Tachycardia (140 bpm), BP 162/102 mmHg, respiratory rate 28/min
13:20	Myoclonic seizures on the shoulders and neck. Tachycardia (140 bpm), BP 169/120 mmHg, respiratory rate 35/min	Admitted to the intensive care unit. Clonazepam 1.0 mg (per oral), intralipid (20%) 100 ml, and started landiolol 0.01 mg/kg/min
16:10	No myoclonus was seen after the initial dose of cyproheptadine. Vital was stabilized soon.	Cyproheptadine 12 mg (per oral)
22:00		Cyproheptadine 4 mg (per oral)
Day 2 6:00		Cyproheptadine 4 mg (per oral) Moved to general ward
Day 4		Discharged from the hospital