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Titubation and Essential Tremor due to Citalopram
Treatment: Case Report

Associate Professor, Trakya University, School of Medicine, Department of Neurology Correnpondence author:Kemal Balci, MD, Trakya University School of Medicine Neurology Department 22030, Edirne / TurkeyPhone: +902842129062E mail: [email protected] 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
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 tre-
tremor strongly associated with citalopram usage.
Citalopram is a typical drug of SSRI used in seroto- nergic dysfunction related disorders, including dep- ression, anxiety, panic disorders, obsessive-compulsi- A 26 years-old medical student admitted to our cli- ve disorder and premenstrual dysphoria (Pollock nic for head tremor after citalopram usage for depres- 2001). Besides headache, tremor is considered as the sion. He presented to the outpatient adolescent second most common neurological adverse effect of psychiatric unit with depressive mood and was tre- selective serotonin reuptake inhibitors (SSRIs). Abnor- ated with citalopram 20 mg/day. Two weeks later de- mal movements such as acute dystonia, dyskinesias, veloped head tremor and postural tremor in the up- akathisia, Parkinsonism, exacerbations of Parkinson’s per extremities. Family history for tremor and other disease, and possibly the neuroleptic malignant movement diseases was negative. His medical history syndrome have been associated with the usage of unremarkable, and there was no history of any neuro- SSRIs. There are citalopram induced akathisia, jaw tre- logical illness or extrapyramidal symptoms. He had mor, bruxism, serotonin syndrome, and dystonic rab- no history of neuroleptic or other neuropsychiatric bit syndrome case reports in the literature (Najjar and Price 2004, Arshaduddin et al 2004, Parvin and Swartz Systemic examination, blood pressure, and heart 2005). We report of a case with titubation and essential rate were normal. On neurologic examination sensati- New/Yeni Symposium Journal • www.yenisymposium.net Ekim 2010 | Cilt 48 | Say› 4
on, motor power, and deep tendon reflexes were nor- probability of entering into oscillation in response to mal in all extremities. Cranial nerve examination was synaptic input (Sugihara et al 1995).
unremarkable. There was no rigidity. Tongue or pala- The drugs decreasing levels of the serotonin in the tal tremor has not been seen. However, on stretching inferior olive may spoil the motor system towards un- his arms, rhythmic, 7-8 Hz hand tremor was noted bi- controlled oscillations causing tremors and as a result laterally upper extremities. The tremor was accentu- serotonin hyperstimulation occurs (Barragan et al ated by anxiety and stress. Also he has titubation.
Laboratory examination revealed normal hemog- Above mentioned mechanism probable explains lobin, red, white blood cells, platelet and differential the etiology of the tremor due to citalopram.
count, blood glucose, liver and kidney function tests, Abnormal movements such as jaw tremor, bru- serum electrolytes, coeruloplasmin and serum copper xism, dystonia, deterioration of parkinsonian tremor content. The erythrocyte sedimentation rate, serum after citalopram treatment reported. But there is no es- protein and electrophoresis were normal. The thyroid sential tremor or titubation after citalopram treatment.
function tests (T - triiodothyronine, T - thyroxine) were within normal limits. Cranial magnetic resonan- CONCLUSION
ce imaging was normal. Citalopram treatment was Citalopram must be taken in mind for causing or stopped, and no other treatment was instituted. After aggravating abnormal movement, both essential tre- cessation of citalopram there was no deterioration in mor and titubation may be explained by inhibitory view of the psychiatric and neurological sense. One impact on central dopaminergic activity.
week after the cessation of the citalopram both tituba-tion and postural tremor completely disappeared.
Arshaduddin M, Al Kadasah S, Biary N, Al Deeb S, Al Moutaery DISCUSSION
K, Tariq M (2004) Citalopram, a selective serotonin reuptake Citalopram, a potent and the most selective SSRI inhibitor augments harmaline-induced tremor in rats. BehavBrain Res; 153: 15-20.
available, is a widely used antidepressant. Basically, Barragan LA, Delhaye-Bouchaud N, Laget P (1985) Drug-indu- serotonergic projections inhibit dopamine function by ced activation of the inferior olivary nucleus in young rab- means both inhibition of firing of the dopamine cells bits: Differential effects of harmaline and quipazine.
and inhibition of synaptic release and, probably, synthesis of dopamine in the midbrain, striatum and Ferre S, Cortes R, Artigas F (1994) Dopaminergic regulation of cortex. Several other observations suggest that dopa- the serotonergic raphe-striatal pathway: microdialysis stud-ies in freely moving rats, J. Neurosci; 14: 4839–4846.
mine and serotonin systems modulate each other to Guan XM, McBride WJ (1989) Serotonin microinfusion into the act in a co-operative manner in the forebrain (Guan ventral tegmental area increases accumbens dopamine and McBride 1989, Ferre et al 1994).
release. Brain Res Bull; 23: 541–547.
There is a central oscillator at olive-cerebellar-tha- Najjar F, Price LH (2004) Citalopram and dystonia. J Am Acad lamic-cortical-spinal level acting as the primary gene- rator of essential tremor, which is regulated by perip- Parvin MM, Swartz CM (2005) Dystonic rabbit syndrome from heral component. It is believed that the involvement citalopram. Clin Neuropharmacol; 28: 289-291.
Pollock BG (2001) Citalopram: a comprehensive review. Exp of serotonin in modulation of olivary excitability by allowing the membrane potential of olivary neurons Tarlaci S (2004) Citalopram-induced jaw tremor. Clin Neurol to be maintained with a narrow range so as to prevent them from generating uncontrollable rhythmic firing Tseng WP, Tsai JH, Wu MT, Huang CT, Liu HW (2005) Citalop- (Barragan et al 1985). Although serotonin performs in ram-induced serotonin syndrome: a case report. Kaohsiung an excitatory effect within the inferior olive, the loss of a tonically excitatory input may bias olivary neurons Sugihara I, Lang EJ, Llinas R (1995) Serotonin modulation of in- ferior olivary oscillation and synchronicity: a multiple-elect- toward hyperpolarization, thereby increasing their rode study in the rat. Eur J Neurosci; 7: 521–534.
New/Yeni Symposium Journal • www.yenisymposium.net Ekim 2010 |
Ekim 2010 Cilt 48 | Say› 4

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