EPMS Under Antidepressive Therapy With Fluvoxamine and Concomitant Antibiotic Therapy With Clindamycin

Abstract

A 32-year-old man with a history of DSM-IV recurrent depression for 10 years was admitted in August 2005 for a major depressive episode without psychotic features. His Hamilton Depression Rating Scale (HDRS 17) score was 25, with the main complaints being depressive mood, adynamia, anhedonia, difficulties in concentration, and hemicrania as a somatic symptom. Before admission the last medication consisted of 100 mg fl uvoxamine for 10 days in a stable dose. Up to then no side effects had occurred. No signifi cant fi ndings were obtained by the physical examination. EEG, ECG, and MRI showed no abnormalities, and the patient had no history of seizures. After admission the dose of fl uvoxamine was increased to 200 mg within one day. Within four weeks of treatment under this regimen, the patient became euthymic. His HAMD 17 score decreased to 6 points. No side effects occurred under this treatment. During his last week in hospital the patient developed an axillary furuncle. Upon the recommendation of the consulted dermatologist, an antibiotic medication with clindamycin 300 mg per day was initiated. Forty-eight hours later the patient developed severe orofacial dyskinesia. Further diagnostics such as neurological and physical examination showed no abnormalities. In addition, no hint of any further substance intake could be found. After intravenous application of 2.5 mg biperiden, the orofacial dyskinesia disappeared immediately. The antibiotic medication was discontinued right away. The directly measured blood level of fl uvoxamine resulted in a subtherapeutic fl uvoxamine level of 90 ng / mL (normal range 150 -300 ng / mL [1] ). Thirty-six hours after treatment with clindamycin was stopped, we began a new antibiotic medication (Unacid). Under this treatment no further clinical abnormalities occurred, especially no extrapyramidal adverse effects. The patient remained euthymic and was dismissed in a stable condition. Psychiatric and neurological adverse effects have been reported with use of several antibiotics [2,4,5] . However the development of dyskinesia is described only in patients who were treated with substances such as ofl oxacin [2] . To our knowledge no reports of extrapyramidal adverse effects associated with clindamycin exist. On the other hand, considering the close temporal connection between the intake of clindamycin and the development of EPS and given that fl uvoxamine was administered at a stable dose for more than four weeks, we suggest that there might be a causal connection as well. However there are no data suggesting clindamycin itself to be directly associated with the development of EPS. Furthermore, it is diffi cult to fi nd a direct neurobiological explanation considering that clindamycin is not known to infl uence the transmitter systems of dopamine, noradrenaline, or serotonin [3] . Despite the measured subtherapeutic blood level of fl uvoxamine at this time, there is a possibility that the origin of EPS was based upon fl uvoxamine and pharmacological interactions between clindamycin and ...

Extrapyramidal Reactions Associated With Serotonergic Antidepressants

“…Nine patient cases were identified in the previous review, 8 and 18 cases are summarized in our current review. [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] SSRI treatments were implicated in 72.2% of cases (citalopram/escitalopram, fluoxetine, paroxetine most frequently) with venlafaxine and duloxetine comprising the other cases. Monotherapy was present in 11.1% of cases, and treatments with D2 receptor antagonism were present in 27.8% of cases.…”

“…Our PubMed search identified 574 published articles, and of these, a total of 110 citations were selected for review; 86 (78%) citations, yielding 91 patient cases, were determined as relevant. There were 17 cases of akathisia, [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] 18 cases of dyskinesia, [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] 27 cases of dystonic reactions, 19 cases of parkinsonism, 27,77-94 and 10 "mixed" EPR cases. 19,[95][96][97][98][99][100][101][102][103] An overview of each case report by EPR category can be found in Table 1.…”