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Ptjournal.apta.org

Misdiagnosis of Serotonin Syndrome
as Fibromyalgia and the Role of
Physical Therapists
Gregory M Alnwick
GM Alnwick, PT, DPT, is Staff Background and Purpose.
Physical Therapist and Master Cli- With increased use of serotonergic medications, a nician, Genesis Rehabilitation Ser- condition triggered by serotonin excess within the brain and spinal cord has emerged vices, Gorham Outpatient Clinic, and may be gaining prevalence. The purposes of this case report are to describe how Gorham, NH. Mailing address: 4 to identify serotonin syndrome in a patient who is taking citalopram (a selective Woodbound Rd, Gorham, NH serotonin reuptake inhibitor) on the basis of signs and symptoms and to promote the 03581 (USA). Address all corre-spondence to Dr Alnwick at: ability of physical therapists to recognize such signs and symptoms.
Case Description. The patient was a 42-year-old woman referred for physical
[Alnwick GM. Misdiagnosis of se- therapy with a diagnosis of fibromyalgia. The physical therapist recognized that the rotonin syndrome as fibromyalgiaand the role of physical therapists.
patient's symptoms did not resemble those of fibromyalgia and recommended referral Phys Ther. 2008;88:xxx–xxx.] to a neurologist for further diagnostic testing.
2008 American Physical Therapy The patient was referred to a neurologist, who diagnosed serotonin syndrome related to the use of citalopram. The patient was weaned off citalopramand made a successful recovery, with scores on the Oswestry Disability Indexdecreasing from 70% to 28% at discharge from the physical therapy treatment and to0% at the 6-month follow-up. The patient has since returned to her prior activity level,which includes skiing, motorcycle riding, and working at her consulting firm.
Discussion. This case report demonstrates how careful evaluation by the physical
therapist indicated that signs and symptoms were not consistent with fibromyalgia,
and further medical evaluation revealed the actual diagnosis of serotonin syndrome.
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Diagnosis of Serotonin Syndrome
Forphysicaltherapiststobecome tionofSSRIsisnotfullyunderstood, cologic treatment with serotoner- it is believed that they inhibit the gic agents that increase serotonin ers and to meet the American reuptake of serotonin at the neuro- activity.4,7 It is thought to occur Physical Therapy Association goal of nal synapse.5 Citalopram was ap- as a result of excess stimulation Vision 2020,1 careful examination proved by the US Food and Drug of the 5-hydroxytryptamine 1A (5- and evaluation procedures must be Administration for the treatment of HT ) receptor and possibly the used to question the referral diagno- depression in adults in July 1998.
5-hydroxytryptamine 2 (5-HT ) re- sis rather than to blindly proceed It is administered orally, and peak ceptor.8–11 Serotonin syndrome may with treatment for fibromyalgia and concentrations in plasma are at- result from an excess of synaptic se- other disorders of the neuromuscu- tained about 4 hours after dosing.
rotonin following the use of sero- lar and musculoskeletal systems. As Its half-life in an individual who is tonergic agents alone or in com- explained in the Guide to Physical healthy is 35 hours. Indications for Therapist Practice,1 physical thera- enhancing drugs.6 In most cases, SS pists should engage in an exami- depression, panic disorder, and post- has a rapid onset, within minutes to nation process that includes taking a traumatic stress disorder. Some con- hours, although it can occur over a history, conducting a systems re- period of days, weeks, or even view, and performing tests and tinuation, bipolar disorder, bleeding, months after the start of treatment measures to identify potential and use in children, driving or operating with various SSRIs.4,12 The incidence existing problems.1 Throughout the machinery, mania, and seizure dis- of SS is, in large part, unknown. The examination, data are gathered to orders; a more extensive list of con- variable and nonspecific nature of evaluate and to form clinical judg- traindications and reasons for pre- its presentation makes it difficult to ments.2 These judgments may con- caution is shown in Appendix 1.
diagnose; therefore, it has gone un- sist of formulating a treatment plan Adverse reactions to citalopram5 are derreported.8 Signs and symptoms or suggesting referral to the proper shown in Appendix 2. The use of of SS may consist of mental status medical care provider.
SSRIs for the treatment of various changes, with acute manifestations psychiatric disorders is increasing; consisting of cognitive behavioral As physical therapists conduct their consequently, the incidence of re- changes, neuromuscular excitability, assessments, it is critical to investi- ported side effects, such as extra- autonomic instability, and pain.4,8 Se- gate the presence of any signs or pyramidal movement disorders like rotonin syndrome also appears to be symptoms that may indicate the those seen in serotonin syndrome dose related, with the dose of the need for referral to the most appro- (SS), also is increasing.6 medication affecting both the likeli- priate health care professional. It is hood of developing SS and the sever- especially important to obtain a de- In order to comprehend SS, it is ity of the clinical presentation.4,12,13 tailed history from any patient with necessary to have an understanding Because the signs and symptoms a diagnosis of fibromyalgia, a syn- of serotonin. The actions of seroto- may overlap those of other chronic drome of unknown etiology that is nin in the peripheral nervous system pain syndromes, a diagnosis is made characterized by chronic widespread include vasoconstriction via smooth on clinical grounds.4 joint and muscle pain,3 or other muscle stimulation, platelet aggre- chronic pain syndromes. If a detailed gation, uterine contraction, intesti- Serotonin syndrome is not detected history is not obtained, then signifi- nal peristalsis, and bronchoconstric- by laboratory tests or diagnostic im- cant information, including medica- tion. In the central nervous system, aging. Sternbach14 has set forth diag- tions, may be omitted, increasing the serotonin has effects on controlled nostic criteria for this syndrome: chances of misdiagnosis and inap- behavior, attention, affect, pain per- ception, aggression, motor control, 1. At least 3 of the following clinical temperature control, sleep, appetite, features should occur coincident With the increased use of serotoner- and sexual function. Because sero- with the addition of or increase in gic medications, a condition trig- tonin is unable to cross the blood- dosage of a known serotonergic gered by serotonin excess within the brain barrier, it must be produced brain and spinal cord has emerged both centrally, within the brain and may be gaining prevalence.4 stem, and peripherally, within the tion, myoclonus, hyperreflexia, Selective serotonin reuptake inhibi- diaphoresis, shivering, tremor, di- tors (SSRIs), including citalopram, arrhea, incoordination, and fever.
are used to treat depression. Al- Serotonin syndrome is an iatro- though the exact mechanism of ac- genic disorder induced by pharma- 2. Other etiologies (infections, met- Diagnosis of Serotonin Syndrome
abolic disorders, and substance abuse or withdrawal) need to be Time Line of Events 6 y prior to diagnosis of serotonin The patient began taking citalopram; the exact start 3. A neuroleptic agent should not date is unknown.
have been started or increased in 4 y prior to diagnosis of SS The patient reported intermittent nausea and dosage prior to the onset of the vomiting with a slow and gradual onset and was signs and symptoms listed above.
considered to have Me´nie re disease.
2 y prior to diagnosis of SS Symptoms continued to worsen, with increased Mason et el8 and Chechani15 also dis- bouts of nausea and vomiting daily and increasedheadaches. The patient consulted numerous cussed pain as a symptom of SS. Be- specialists, with no significant improvement.
cause SS is diagnosed on the basis ⬃1 y prior to diagnosis of SS The patient began to have mental symptoms, such of symptoms and signs, some pa- as loss of memory and confusion.
tients may experience mild symp- 6 mo prior to diagnosis of SS Symptoms continued to worsen. The patient's toms for weeks before progressing short-term memory was worsening, along with an to a more severe form of the syn- increase in other symptoms and pain.
drome.12 Therefore, the purposes of 2 mo prior to diagnosis of SS The patient was referred for physical therapy for the this report are to bring attention to first time. At this time, the patient was notworking, needed assistance with basic activities of some of the signs and symptoms of daily living (ADL), and was unable to perform SS that may be overlooked if their instrumental ADL. The patient scored 70% on the onset is gradual and to promote the first Oswestry Disability Index (ODI)questionnaire.
ability of physical therapists to iden-tify such signs and symptoms in pa- 1 mo prior to diagnosis of SS The patient scored 62% on the second ODI questionnaire and continued to have many of the tients with SS.
same symptoms, but at a slightly lesser degree.
Diagnosis of SS made by An initial evaluation was performed by a neurologist. Citalopram was tapered off and discontinued. Within 2 wk of the discontinuation The initial physical therapy visit con- of citalopram, the patient reported significantdecreases in all of her symptoms.
sisted of a thorough evaluation by 3 mo after diagnosis of SS The patient was discharged from physical therapy use of a systems approach as de- and scored 28% on the ODI questionnaire. From scribed in the Guide to Physical referral to discharge from physical therapy, the Therapist Practice.1 Two months patient was seen for a total of 41 visits.
prior to receiving the neurologist's 9 mo after diagnosis of SS At a follow-up examination, the patient scored 0% diagnosis of SS, the patient's primary on the ODI questionnaire. She also reportedreturning to work and hobbies.
care physician (PCP) referred her forphysical therapy with a diagnosis offibromyalgia, identified by increasing any relationship between time of tient had experienced many similar pain and weakness. Her pain rating day and intensity of pain, nor was at the time of the initial evaluation there a specific pain pattern. The pa- was 8 of 10 and ranged from a low of tient reported that pain increased History of Course of Symptoms
4 of 10 with rest to a high of 10 of 10 with activity and did not diminish Table 1 summarizes the time line of with increased activity on an 11- with any specific position. The appli- point (0 –10) numeric pain scale, in cation of a hot pack, however, did which 0 represented "no pain" and seem to provide a small amount of Four years prior to diagnosis.
10 represented "the worst pain pos- relief. The patient described her pain The patient had been taking citalo- sible."16,17 The numeric pain scale as throbbing throughout her extrem- pram (20 mg per day) since 1998 for has been shown to have high test- ities, with burning and a sense of the treatment of depression that was retest reliability (intraclass correla- tightness along the spine. With in- related to abuse that she had experi- tion coefficient⫽.96) and a strong creased pain, she also had increased enced as a child. She began to expe- correlation (r⫽.85) with data col- nausea, with or without vomiting.
rience symptoms approximately 2 lected using a visual analog scale.16 There were also signs of dizziness years after starting citalopram. Be- The patient reported that pain rang- that did not appear to increase or cause of dizziness, she was consid- ing from 4 of 10 to 10 of 10 was decrease with the degree of pain.
re disease, an id- constant. There did not appear to be Prior to the initial evaluation, the pa- iopathic syndrome of endolymphatic Diagnosis of Serotonin Syndrome
hydrops.18 The American Academy of At the time of the Otolaryngology head and neck sur- I performed a physical examination initial evaluation, the patient com- gery criteria for Me 2 months prior to the diagnosis of SS the triad of vertigo, hearing loss, and being made by her neurologist.
Oswestry Disability Index (ODI) ques- tionnaire. The ODI is a reliable and Vital signs.
Vital signs were not valid tool19 designed to capture a pa- Two years prior to diagnosis.
noted at the time of the initial visit.
tient's perceived disability through re- The patient began to have gastroin- sponses to a series of questions relat- testinal tract problems consisting of ing to activities of daily living and increased bouts of nausea and vom- don reflexes were grossly 2 in bilat- degree of pain experienced with a iting with a slow and gradual onset.
eral upper extremities (biceps, tri- specific activity. Each section is de- She also began to experience head- ceps, and brachioradialis). Patellar signed to provide a percentage of and Achilles tendon reflexes were disability. The higher the percent- throbbing pain and hypersensitivity unattainable bilaterally. Nystagmus age, the greater the level of disability to light and sound. She had pain in of greater than 3 beats was observed perceived by the patient.19 her left shoulder, along her spine, bilaterally, along with increased diz- and in many of her joints. She also ziness with finger tracking. The pa- The patient's balance was poor, as experienced left-side weakness, mus- tient had difficulty when she was demonstrated by her need to hold on cle tightness, fluctuating tempera- asked to touch her finger to her nose to a table with both hands in order to and then to touch my finger. Sensa- remain in an upright position in re- tion to light touch was within nor- sponse to light pressure placed upon mal limits, except for hypersensitiv- her shoulders and torso by the ther- One year prior to diagnosis.
ity to very light touch in the entire apist in various directions while she patient had little to no appetite, right lower extremity.
was sitting. Gait assessment dem- bouts of diarrhea, and a sense of full- onstrated a severe antalgic gait with ness and urgency with urination. She the use of a straight cane. The pa- also experienced left-side muscle tion revealed tenderness in a non- tient also exhibited decreased stride aching and spasms that caused her to anatomic pattern throughout the length and stance phase bilaterally have difficulty ambulating and to patient's extremities and body. These with a step-to-gait pattern. She re- need a straight cane. The patient be- findings did not coincide with the ported that there were times when gan to have mental symptoms, such criteria for fibromyalgia.3 Because her legs would "give out" without as confusion and decreased memory.
of the patient's increased pain level, any apparent warning. This problem She also had dilated pupils, vertigo, a proper assessment of gross range had led her to have several recent and dysarthria.
generating capacity) was not per- Six months prior to diagnosis.
formed. The patient's roommate re- The patient experienced intermit- ported that she spent much of the At the time of the initial evalua- tent fatigue, bouts of increased night "jumping" and having muscle tion, the patient reported taking sweating, episodes of feeling very spasms with jerking motions in all the following medications: cariso- cold, and nightmares. Mental symp- parts of her body. This problem se- prodol for muscle spasms, clonaz- toms, including confusion and de- verely limited her ability to sleep for epam (1 mg) nightly 4 or 5 times creased memory, were worsening.
more than 2 hours at a time.
per week for anxiety, gabapentin She complained of increased pain (300 mg) 3 times per day for pain, throughout her spine, joints, and ex- and citalopram (20 mg) for anxiety tremities as well as left-sided weak- and depression. She reported having ness of the upper and lower extrem- There were no significant findings taken carisoprodol, clonazepam, and ities. She had decreased sensation in for the cardiovascular, endocrino- gabapentin for several years and cita- the lateral aspects of both hands.
logic, and integumentary systems.
lopram for the preceding 6 years.
Before citalopram, she had taken ser- The diagnostic criteria set forth by Gastrointestinal tract findings.
traline hydrochloride (also an SSRI) Sternbach,14 combined with the pa- The patient reported gastrointestinal and nefazodone.
tient's history of taking an SSRI, sug- tract symptoms (nausea, vomiting, gested that the above symptoms and difficulty with bowel and blad- were indeed relevant to SS.
der functions).
Diagnosis of Serotonin Syndrome
and the diagnosis was determined, The patient reported having had 2 given the wide array of neurologic Oswestry Disability Index Questionnaire cranial magnetic resonance imaging symptoms and pain symptoms in a (MRI) scans and a computed to- mography (CT) scan of the brain, mended that the patient be referred which were read as normal. She to a neurologist by her PCP. Because had never had a spinal tap or an the patient was reporting some relief Day 1 initial evaluation through therapy, her PCP recom- mended that physical therapy con- Family History and Social Activity
sisting of passive range of motion Follow-up at 6 mo The patient was a 42-year-old woman and gentle manual techniques be who was co-owner of a consulting continued until she saw the neurol- firm. She enjoyed motorcycle riding, ogist. An ODI questionnaire adminis- skiing, playing hockey, and working tered 31 days after the initial physical try; reflexes were 1 to 2⫹; and sen- around her house and yard. She lived therapy evaluation validated the ef- sory examination findings were nor- with her roommate and roommate's fectiveness of treatment and demon- mal. There was a hemiparetic gait children in a 2-story house. At the strated that the patient was indeed with the use of a straight cane and a time of her initial evaluation, she was showing improvement. At this time, high-frequency, low-amplitude tremor unable to go up and down stairs and, she scored 62%; she had scored 70% with adoption. The tremor was not therefore, had relocated to the first at the initial evaluation (Tab. 2).
noted with use of a cane. In addition, floor of the house. She reported that With a minimal detectable change of the patient had pain with swallow- she had a very good support system 5 or 6 points and a minimal clinically ing, coughing, some choking, fre- at home and was able to get all the important difference of 6 points,19 quent headaches, swollen lymph help she needed to perform many the change in the ODI questionnaire nodes, neck pain, pain with breath- activities of daily living that she score from 70% to 62% is a clinically ing, wheezing, heart palpitations, could not perform unassisted. She meaningful sign of improvement. I pain with urination, blood in the also reported a family history of agreed that treatment should con- urine, swelling in the feet and ankles, tinue until the patient regressed, and frequent bouts of diarrhea and syndrome, and depres- reached a plateau, or had met all constipation with blood in the stool.
sion. She had signed an informed The differential diagnosis consisted consent form that was kept on file at re disease, multiple sclero- the outpatient clinic that she at- The neurologic examination pro- sis, pneumonia, other infection pro- tended. Requirements for the Health vided a medical diagnosis of SSRI- cess, carbon monoxide poisoning, Insurance Portability and Account- induced neurologic syndrome, or SS and gastroesophageal reflex dis- ability Act were upheld during the secondary to the use of citalopram.
ease. The impression was that of an time of treatment management as The findings from the neurologist re- extreme case of SS related to well as during the preparation of this port were as follows: pulse was 96 case report. The patient was very beats per minute; respiration rate proactive in reporting her case so was 22 breaths per minute and non- that others would not have to expe- labored; cardiovascular status was If SS is detected early enough and rience what she had experienced.
within normal limits; cognitive status treated appropriately, the prognosis was generally normal; cranial nerves is very good.11 The prognosis de- showed normal funduscopy find- scribed in the Guide to Physical In accordance with the Guide to ings; eye movements, visual fields, Therapist Practice1 notes that over pupil reactivity, and facial strength the course of 2 to 6 months, the physical therapy diagnosis pattern were equal bilaterally and normal; patient will demonstrate optimal for this patient was that of "impaired facial sensation was vaguely and re- muscle performance. The patient muscle performance, 4C."1 This con- producibly decreased in response to also should make a full recovery and clusion was reached on the basis of a all modalities; hearing was within return to premorbid status. The num- thorough evaluation and the inclu- normal limits; the palate and tongue ber of visits expected for this diag- sion and exclusion criteria set forth were at the midline; muscles showed nosis ranges from 6 to 30, depending in the Guide to Physical Therapist unremarkable bulk and normal sym- on factors that may affect the course Practice.1 After the initial physical metric tone; there was significant therapy evaluation was performed left hemiparesis, without asymme- Diagnosis of Serotonin Syndrome
ication regimen consisted of gabap- entin 3 times per day at doses of 600, The purposes of this case report cause of the amount of pain that the 600, and 900 mg, nortriptyline at were to bring attention to some of patient was experiencing at the time doses of 25 mg in the morning and the signs and symptoms associated of the initial evaluation and her re- 75 mg at night, and clonazepam (1 with an atypical presentation of SS, ports of nausea and dizziness and mg, as needed).
consisting of pain and a gradual on- history of falls, I determined that she set, which may be misdiagnosed as would not be able to tolerate any With the changes in medications, the fibromyalgia, and to promote the type of aggressive treatment or ther- patient was able to tolerate more ag- ability of physical therapists to iden- apeutic exercise. Therefore, physical gressive treatment and physical ther- tify such signs and symptoms in pa- therapy treatment consisted of very apy interventions. Range-of-motion tients with SS. The patient described gentle passive range-of-motion, myo- activities gradually progressed from in this report had been referred for fascial, and massage techniques, en- passive to active assistive and, fi- physical therapy with a diagnosis of ergy conservation techniques, and nally, to active range of motion with relaxation techniques. These tech- resistance. Treatment also included a pain. Her condition had been mis- niques have been shown to be effec- walking program on the treadmill diagnosed for a little over 2 years.
and outside, a progressive-resistance This case report describes the pro- chronic pain.20–22 exercise program, and instruction on cess by which the physical therapist a home exercise program addressing was able to base decisions on a de- Second intervention period.
the core muscle group as well as the tailed history and clinical signs and tial treatment by the neurologist symptoms that did not resemble fi- (June 18, 2004) consisted of tapering bromyalgia. This process resulted in off and discontinuing citalopram, a referral to a neurologist for further with an acute-episode rescue consist- Within 2 weeks after withdrawal of evaluation and, ultimately, a final di- ing of diazepam (5 mg), as needed.
the citalopram, the patient reported agnosis of SS by the neurologist.
The patient also began taking a tricy- feeling less dizzy, experiencing less clic antidepressant at a dose suffi- pain, and no longer needing her cane Serotonin syndrome was originally cient to restore normal sleep (25 mg, to ambulate. Her strength improved described in animals pretreated with increasing to 50 mg after 1 week).
from the inability to tolerate any 1-tryptophan and given various mono- She was advised to avoid clonaz- resistance to the ability to tolerate 4 amine oxidase inhibitors or other sero- epam. After the second appointment to 4⫹ of 5 grossly in both upper tonin precursors in combination with with the neurologist (1 month after and lower extremities. An ODI ques- drugs that increase their bioavailabil- diagnosis was made), the medication tionnaire was administered at the ity. First described in humans in 1960,8 regimen consisted of gabapentin end of the treatment. At that time, SS is thought to be induced by the (300 mg) 3 times per day and the the patient scored 28%; the change combined activation of 5-HT continuation of nortriptyline (50 mg).
in scores is a clinically significant 5-HT receptors.22 Since then, numer- Two months after her initial appoint- sign of improvement. Strength was ous articles have been published on ment with the neurologist, the gaba- grossly within normal limits, pain the topic.4,6–13,15,23,24 It is questionable pentin dosage was increased to 3 was rated as 0 to 1 of 10, and the as to why so many cases have been times per day, at doses of 600, 600, patient was walking without any as- misdiagnosed, as with the patient de- and 900 mg, because of an increase sistance or deviations. After the pa- scribed in this case report. However, in pain. Diazepam was discontinued tient was discharged, she followed in this particular case, the patient had and clonazepam (1 mg, as needed) up approximately 6 months later to a gradual onset rather than the typical was resumed at this time, and nor- report that she had no residual ef- acute onset seen in other SS cases. It is triptyline (50 mg) was taken only at fects, with the exception of some important not to overlook even minor, night. Three months later, the med- short-term memory difficulties. She initial symptoms, because they can ication regimen consisted of the con- has since returned to work; she has rapidly become severe.
tinuation of nortriptyline and gabap- been able to tolerate her prior activ- entin, and bupropion (150 mg) was ity level, which includes skiing, mo- The diagnosis of SS also is made dif- introduced. This regimen was con- torcycle riding, cutting and splitting ficult by the overlap of its symptoms tinued until the next appointment wood, and other hobbies and inter- with those of neuroleptic malignant with the neurologist. Upon the pa- ests; and she scored 0% on a final syndrome and extrapyramidal disor- tient's last reported visit with the ODI questionnaire.
ders.6 In this case report, the patient neurologist 9 months later her med- with SS had been misdiagnosed as Diagnosis of Serotonin Syndrome
having fibromyalgia (Tab. 3). Fibro- myalgia is a rheumatologic syndrome Comparison of Signs and Symptoms of Serotonin Syndrome14 and Fibromyalgia9,25 of unknown etiology. It is character- ized by chronic widespread bilateral Mental status changes Bilateral widespread pain in the upper body, upper- and lower-body joint, muscle, (confusion, hypomania) lower body, and spine and spinal pain. The American Col- Pain lasting at least 3 mo lege of Rheumatology 1990 classifi- Tenderness at 11 of 18 specific tender cation criteria for fibromyalgia in- clude diffuse soft-tissue pain with a duration of at least 3 months andpain on palpation in at least 11 of 18 paired tender points.3,25 The patient described in this case report did have diffuse soft tissue pain; how- ever, she did exhibit a change in mental status, agitation, myoclonus, hyperreflexia, tremor, diarrhea, and incoordination. Although there was At least 3 of 10 clinical features must occur coincident with the addition of or an increase in the dosage of a known serotonergic agent.
tenderness throughout the body, thetreating therapist did not observetenderness at the specified 11 of 18tender points necessary for a diagno- who, after obtaining a detailed his- with this clinical presentation, it sis of fibromyalgia.3 The major symp- tory and performing a physical exam- might be beneficial to refer them for tomatology that led to the suggestion ination, realized that the symptoms physical therapy in order to obtain a that the patient be referred to a neu- exceeded those of fibromyalgia and full-systems-approach evaluation and rologist was that of neurologic signs suggested that the patient be re- begin conservative treatments.
consisting of, but not limited to, nys- ferred to a neurologist, who also ob- tagmus, reflex disturbances, diffi- tained a detailed history, performed Physical therapists usually are able to culty with memory, sensory distur- an examination, and diagnosed her spend a considerable amount of time bances, and a history of falls, which working closely with patients and are not symptoms of fibromyalgia.
are in a good position to identify symptoms that are either consistent The criteria described above can aid ported that there was weak efficacy or inconsistent with a patient's diag- in the diagnosis of SS. However, it is for the use of ultrasound, chiroprac- nosis. They can spend an hour to important to rule out other, similar tic care, and electrotherapy in pa- perform an initial evaluation and pro- disorders and to understand that SS tients with fibromyalgia. However, vide frequent follow-up appoint- can have pain as a primary symptom they did find strong efficacy for car- ments, 2 or 3 days per week for 4 to and can have a gradual onset rather diovascular activity, patient educa- 8 weeks, depending on the diagno- than an acute onset. At present, tion, and exercise therapy, all of sis. This time spent with the patient there is no gold standard that would which are within the scope of phys- allows the physical therapist to col- confirm or reject this syndrome. The ical therapist practice.1,25 Given the lect significantly more information patient described in this case report initial diagnosis of fibromyalgia and and perform trials of various treat- did have the majority of symptoms the symptoms of pain in this patient, ments, including modalities, exer- required to make a diagnosis of SS, as it would have been appropriate to cise, and manual techniques, each of set forth by Sternbach.14 Prior to be- have referred this patient for physi- which allows the physical therapist ing diagnosed with SS, the patient cal therapy earlier. I am unaware of to assess and reassess the patient's had been examined by several phy- any evidence in the areas of physical status. This information then can be sicians, including rheumatologists, therapy and the treatment of SS.
added to the information collected psychiatrists, and numerous PCPs.
Therefore, more research should be by the physician, resulting in a more All of them had missed the diagnosis done on SS, the mechanisms of pain accurate diagnosis and enabling the of SS. After having this disorder for and muscle weakness caused by best treatment possible. In this par- more than 4 years, the patient was SSRIs (including citalopram), and ticular case, the treating therapist eventually referred for physical ther- their responses to physical therapy was able to collect significant infor- apy. It was the physical therapist interventions. In general, for patients mation, including prior health status, Diagnosis of Serotonin Syndrome
time line of events leading up to cur- The author thanks the patient for her coop- 11 Birmes P, Coppin D, Schmitt L, Lauque D.
Serotonin syndrome: a brief review. CMAJ. rent symptoms, and assessments of eration and willingness to share her storyand Joyce Leclerc, Health Science Librarian, the musculoskeletal, neuromuscular, Androscoggin Valley Hospital, for her assis- 12 Manos GH. Possible serotonin syndrome
tance in obtaining reference articles. The au- associated with buspirone added to flu-oxetine. Ann Pharmacother. 2000;34: nary systems. The information col- thor also thanks Dr Heather Alnwick, Dr lected from this patient led to her Maggie Moore-West (Franklin Pierce Univer- 13 Mackay FJ, Dunn NR, Mann RD. Antide-
ultimate referral to a neurologist.
sity), Dr Donald West (Medical Director of pressants and the serotonin syndrome in the Psychiatric Inpatient Program, Dart- general practice. Br J Gen Pract. 1999; Once the correct diagnosis was ob- mouth Hitchcock Medical Center), Dr Tad 49:871– 874.
tained, proper measures were taken.
Pfeffer (The University of Colorado at Boul- 14 Sternbach H. The serotonin syndrome.
The patient was gradually weaned der), Dr Anne Pfeffer, and Heidi Guinen, Am J Psychiatry. 1991;148:705–713.
off citalopram and switched to a non- MSW, LCSW, for their suggestions.
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Appendix 1.
Appendix 2.
Contraindications and Precautions for Adverse Reactions to Citalopram5 Impaired cognition • Abrupt discontinuation • Bipolar disorder • Breast feeding • Hypersensitivity to citalopram Nausea or vomiting Neuroleptic malignant syndrome • Use in neonates • Use of a monoamine oxidase Reasons for precaution Serotonin syndrome • Cardiac disease Sinus tachycardia • Driving or operating Gastrointestinal tract bleeding Suicidal ideation • Electroconvulsive therapy • Hepatic disease • Renal failure • Renal impairment • Seizure disorder

Source: http://ptjournal.apta.org/content/ptjournal/early/2008/04/17/ptj.20060208.full.pdf