New/Yeni Symposium Journal • www.yenisymposium.net 299 Ekim 2010 | Cilt 48 | Say› 4 INTRODUCTION
Citalopram is a typical drug of SSRI used in seroto-nergic dysfunction related disorders, including dep-ression, anxiety, panic disorders, obsessive-compulsi-ve disorder and premenstrual dysphoria (Pollock 2001). Besides headache, tremor is considered as the second most common neurological adverse effect of selective serotonin reuptake inhibitors (SSRIs). Abnor-mal movements such as acute dystonia, dyskinesias, akathisia, Parkinsonism, exacerbations of Parkinson’s disease, and possibly the neuroleptic malignant syndrome have been associated with the usage of SSRIs. There are citalopram induced akathisia, jaw tre-mor, bruxism, serotonin syndrome, and dystonic rab-bit syndrome case reports in the literature (Najjar and Price 2004, Arshaduddin et al 2004, Parvin and Swartz 2005). We report of a case with titubation and essential
tremor strongly associated with citalopram usage. CASE
A 26 years-old medical student admitted to our cli-nic for head tremor after citalopram usage for depres-sion. He presented to the outpatient adolescent psychiatric unit with depressive mood and was tre-ated with citalopram 20 mg/day. Two weeks later de-veloped head tremor and postural tremor in the up-per extremities. Family history for tremor and other movement diseases was negative. His medical history unremarkable, and there was no history of any neuro-logical illness or extrapyramidal symptoms. He had no history of neuroleptic or other neuropsychiatric therapy and alcohol intake.
Systemic examination, blood pressure, and heart rate were normal. On neurologic examination
sensati-Ekim 2010 | Cilt 48 | Say› 4
Titubation and Essential Tremor due to Citalopram
Treatment: Case Report
Yahya Celik*, Kemal Balci*
* Associate Professor, Trakya University, School of Medicine, Department of Neurology Correnpondence author:
Kemal Balci, MD, Trakya University School of Medicine Neurology Department 22030, Edirne / Turkey Phone: +902842129062
E mail: kemalbalcidr@yahoo.com Fax: +902842357652
ABSTRACT
Many drugs can cause or aggravate tremor. Abnormal movements such as jaw tremor, bruxism, dystonia, and serotonin syndrome to due to citalopram were reported in the literature. We pre-sented a case of a transient titubation and essential tremor associated with citalopram.
Keywords: citalopram, SSRIs, titubation, essential tremor ÖZET
S‹TALOPRAM TEDAV‹S‹NE BA⁄LI T‹TÜBASYON VE ESANS‹YEL TREMOR: B‹R VAK’A TAKD‹M‹
Birçok ilâç tremora neden olabilir veya mevcut tremoru artt›rabilir. Literatürde sitalopram kullan›-m›na ba¤l› geliflen çene tremoru, bruksizm, distoni ve serotonin sendromu gibi anormâl hareket-ler bildirilmifltir. Bu yaz›da sitalopram kullan›m›na ba¤l› geliflen geçici titübasyon ve esansiyel tre-moru olan bir vak’a sunulmufltur.
Anahtar Kelimeler: sitalopram, seçici serotonin geri al›m inhibitörleri, titübasyon, esansiyel
New/Yeni Symposium Journal • www.yenisymposium.net 300 Ekim 2010 | Cilt 48 | Say› 4Ekim 2010 | Cilt 48 | Say› 4
on, motor power, and deep tendon reflexes were nor-mal in all extremities. Cranial nerve examination was unremarkable. There was no rigidity. Tongue or pala-tal tremor has not been seen. However, on stretching his arms, rhythmic, 7-8 Hz hand tremor was noted bi-laterally upper extremities. The tremor was accentu-ated by anxiety and stress. Also he has titubation.
Laboratory examination revealed normal hemog-lobin, red, white blood cells, platelet and differential count, blood glucose, liver and kidney function tests, serum electrolytes, coeruloplasmin and serum copper content. The erythrocyte sedimentation rate, serum protein and electrophoresis were normal. The thyroid function tests (T3 - triiodothyronine, T4 - thyroxine) were within normal limits. Cranial magnetic resonan-ce imaging was normal. Citalopram treatment was stopped, and no other treatment was instituted. After cessation of citalopram there was no deterioration in view of the psychiatric and neurological sense. One week after the cessation of the citalopram both tituba-tion and postural tremor completely disappeared.
DISCUSSION
Citalopram, a potent and the most selective SSRI available, is a widely used antidepressant. Basically, serotonergic projections inhibit dopamine function by means both inhibition of firing of the dopamine cells and inhibition of synaptic release and, probably, synthesis of dopamine in the midbrain, striatum and cortex. Several other observations suggest that dopa-mine and serotonin systems modulate each other to act in a co-operative manner in the forebrain (Guan and McBride 1989, Ferre et al 1994).
There is a central oscillator at olive-cerebellar-tha-lamic-cortical-spinal level acting as the primary gene-rator of essential tremor, which is regulated by perip-heral component. It is believed that the involvement of serotonin in modulation of olivary excitability by allowing the membrane potential of olivary neurons to be maintained with a narrow range so as to prevent them from generating uncontrollable rhythmic firing (Barragan et al 1985). Although serotonin performs in an excitatory effect within the inferior olive, the loss of a tonically excitatory input may bias olivary neurons toward hyperpolarization, thereby increasing their
probability of entering into oscillation in response to synaptic input (Sugihara et al 1995).
The drugs decreasing levels of the serotonin in the inferior olive may spoil the motor system towards un-controlled oscillations causing tremors and as a result serotonin hyperstimulation occurs (Barragan et al 1985).
Above mentioned mechanism probable explains the etiology of the tremor due to citalopram.
Abnormal movements such as jaw tremor, bru-xism, dystonia, deterioration of parkinsonian tremor after citalopram treatment reported. But there is no es-sential tremor or titubation after citalopram treatment.
CONCLUSION
Citalopram must be taken in mind for causing or aggravating abnormal movement, both essential tre-mor and titubation may be explained by inhibitory impact on central dopaminergic activity.
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