We discussed a case of a young male with complete C5/6 injury who presents with altered mental status and agitation. While in our rehab unit, he was on multiple medications for neuropathic pain and allodynia including Nortriptyline (started recently), Cymbalta, Morphine and Sudafed, Gabapentin, Baclofen and Lyrica. He had acute onset agitation (shaking his head right/left), fevers, diarrhea and horizontal roving eyes or opsoclonus /ocular clonus. The rest of his exam was non contributory as he suffered from flaccid paralysis below C5. He was diagnosed with serotonin syndrome. He was treated with Ativan and Cyproheptadine with significant improvement. It is important to realize that there are many mimickers of serotonin syndrome and that it is a fatal condition with 11% mortality. Think about this diagnosis when you see acute onset ocular clonus, tachycardia, fever, hypertension, diaphoresis and neuromuscular activation (hyperreflexia and tremor).  See attached case summary.