A 35-year-old woman comes to the urgent care clinic due to fatigue and muscle aches for 2 days. She says, "I rarely have to use a sick day but today I had to because I feel horrible-my nose won't stop running, and I've got a bad headache. I think I'm coming down with the flu." The patient also reports having chills and difficulty sleeping through the night. She took acetaminophen but has had no symptom relief. The patient has a 2-year history of depression treated with paroxetine, which she has not taken for the past few days. She is visiting New York from Chicago for work and forgot to pack her medication. She takes no other medications. The patient drinks a glass of wine on most evenings and does not use tobacco. Temperature is 37 C (98.6 F), blood pressure is 134/86 mm Hg, and pulse is 92/min. On physical examination, the patient appears restless. There is clear nasal discharge, but nasopharyngeal mucosa appears normal. Lungs are clear on auscultation, and heart sounds are normal. The abdomen is soft and nontender. There is a mild tremor in both hands, but no other focal neurological deficits are present. Which of the following is the most appropriate next step in management of this patient?

Question

A 35-year-old woman comes to the urgent care clinic due to fatigue and muscle aches for 2 days.  She says, "I rarely have to use a sick day but today I had to because I feel horrible-my nose won't stop running, and I've got a bad headache.  I think I'm coming down with the flu."  The patient also reports having chills and difficulty sleeping through the night.  She took acetaminophen but has had no symptom relief.  The patient has a 2-year history of depression treated with paroxetine, which she has not taken for the past few days.  She is visiting New York from Chicago for work and forgot to pack her medication.  She takes no other medications.  The patient drinks a glass of wine on most evenings and does not use tobacco.  Temperature is 37 C (98.6 F), blood pressure is 134/86 mm Hg, and pulse is 92/min.  On physical examination, the patient appears restless.  There is clear nasal discharge, but nasopharyngeal mucosa appears normal.  Lungs are clear on auscultation, and heart sounds are normal.  The abdomen is soft and nontender.  There is a mild tremor in both hands, but no other focal neurological deficits are present.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's sudden onset of flulike symptoms (fatigue, myalgias, chills, headache, rhinorrhea), insomnia, and tremor following abrupt discontinuation of paroxetine is suggestive of antidepressant discontinuation syndrome (ADS). Other common ADS symptoms include dizziness, nausea, neurosensory disturbances (eg, paresthesia, "electric shock" sensations, vivid dreams), and psychological symptoms (eg, dysphoria, anxiety, irritability). Symptoms typically begin within 2-4 days of the medication being abruptly stopped or rapidly tapered. Serotonergic antidepressants with a shorter elimination half-life (eg, paroxetine, venlafaxine), higher doses, and longer duration of treatment are associated with more severe ADS symptoms. The pathophysiology of ADS is not entirely elucidated: Longterm use of these antidepressants may affect serotonin levels and transporters (eg, serotonin transporter reduction); upon their abrupt discontinuation, this can lead to hyperserotonergic manifestations, partly due to hypofunction of serotonin transporters (which normally decrease serotonin levels in the synaptic cleft). Effects on other neurotransmitters (eg, norepinephrine) may explain the other manifestations of ADS (eg, rhinorrhea), and flulike symptoms are classic. Reinstitution of a serotonergic antidepressant should result in rapid improvement. Patients prescribed antidepressants with shorter elimination half-lives should be cautioned about the risk of ADS due to accidental or intentional self-discontinuation. (Choice A) Urine toxicology would be low-yield in this patient who has no history or signs of recent drug use, and ADS is a better explanation of her constellation of symptoms in the setting of recently being off paroxetine. (Choices B, C, and F) Although this patient has prominent physical symptoms (eg, fatigue, myalgias, headache), acute symptom onset following missed doses of antidepressant medication is highly suggestive of ADS rather than an infectious etiology, and restlessness and tremor are not consistent with influenza or Lyme disease. Further testing for influenza or serologic testing for Lyme disease is not indicated. Prescribing antibiotics in this patient who is afebrile and shows no signs of bacterial infection would be inappropriate. (Choice D) Tremor, restlessness, and elevated heart rate and blood pressure may be seen with mild alcohol withdrawal. However, alcohol withdrawal would be unlikely in this patient with moderate alcohol consumption and would not explain her chills and rhinorrhea. Educational objective: Abrupt discontinuation or rapid taper of short half-life serotonergic antidepressants can result in antidepressant discontinuation syndrome. Treatment consists of restarting a serotonergic antidepressant. References: Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25721705) A review of the management of antidepressant discontinuation symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/26834969)

A 35-Year-Old Woman Comes to the Urgent Care Clinic Due