Reactions 1280 - 28 Nov 2009

★Citalopram/fluoxetine

Intercostal pain with both drugs and first reportof carotidynia with fluoxetine: case report

A 43-year-old man developed intercostal pain followedby carotidynia during treatment with fluoxetine formigraine and mild depression; he later developedintercostal pain during antidepressant treatment withcitalopram.

The man started receiving fluoxetine 20 mg/day to whichhis severe but occasional migraine attacks and milddepression responded favourably; he also occasionallytook dihydroergotamine mesilate for severe migraines.After approximately 5 months, he gradually developed leftintercostal pain which soon progressed to a bilateral,episodic, steadier, stabbing on deep breathing and trunkmovement; the pain was moderate and distressing. At thistime, he chose to increase his fluoxetine to 40 mg/day toimprove its effect on his migraines. Approximately 2 weekslater, he noticed a swollen, tender mass at the level of theright carotid bifurcation, with severe pulsating painradiating to the ipsilateral jaw upon contralateral headmovement; there was carotid tenderness on palpation.Cervical angiomagnetic resonance and magnetic resonancestudies showed abnormal thickening of the soft tissue ofthe right common carotid and its bifurcation, suggestingcarotidynia.

Fluoxetine was stopped and the man’s carotidynia andintercostal pain completely resolved in 2 weeks.

Two months later, the man underwent two rechallengeswith fluoxetine 20 mg/day. His intercostal and cervical painreturned after 4 weeks of therapy but completely resolvedon both occasions when fluoxetine was stopped. Hesubsequently started antidepressant therapy withcitalopram 10 mg/day and, after 6 weeks, he againdeveloped bilateral intercostal pain and citalopram wasstopped immediately. A rechallenge with citalopramproduced the same symptoms as previously and the painwas repeatedly reversible on withdrawal of the drug; hesubsequently received amitriptyline and valproic acidwhich limited the severity and duration of his headachesbut did not induce pain.

Author comment: "After taking fluoxetine and latercitalopram, our patient experienced intercostal pain followedby carotidynia only after escalating the dose of fluoxetine.Pain was fully reversible on withdrawal of either agent." Hegained "a score of 7 on the Naranjo causality scale, suggestinga ‘probable’ adverse fluoxetine-induced reaction".Jabre MG, et al. Probable fluoxetine-induced carotidynia. Lancet 374: 1061-1062,No. 9695, 26 Sep 2009 - Lebanon 801154861

» Editorial comment: A search of AdisBase, Medline,Embase and the WHO ADR database did not reveal anyprevious case reports of carotidynia associated withfluoxetine.

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Reactions 28 Nov 2009 No. 12800114-9954/10/1280-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved