Abstract
The diagnosis of parkinsonian syndromes in patients with severe depression may be challenging due to overlapping clinical phenomena, especially regarding psychomotor and affective symptoms. [123I]FP-CIT-SPECT is a useful method to detect degenerative parkinsonian disorders. However, some drugs may influence the tracer binding and thus alter the result. We present a case of 56-year-old female inpatient with difficult-to-treat late-onset depression. Since the current major depressive episode (MDE) was accompanied by psychotic features including delusions and hallucinations as well as hypokinesia, stooped posture and hypomimia, underlying degenerative parkinsonism was suspected. The pathologic [123I]FP-CIT-SPECT scan under ongoing antidepressant therapy with bupropion 300 mg/die (serum level of bupropion 43 ng/ml and hydroxybupropion 2,332 ng/ml) showed reduced [123I]FP-CIT binding throughout the striatum. The scan normalized upon a wash-out phase of four half-time periods (serum level of bupropion was 0.4 ng/ml and for hydroxybupropion 80.5 ng/ml). Our report should serve as a cautionary note for use of [123I]FP-CIT in depressed patients, particularly in those treated with drugs interfering with the dopamine transporter. Furthermore, our case argues for a need of consultation of a movement disorder specialist prior to dopamine transporter imaging.
Highlights
The diagnosis of parkinsonian syndromes in patients suffering from severe depression can be challenging
Since there was no further change in the ongoing therapy, in particular concerning venlafaxine and vortioxetine or mirtazapine, we attribute the observed effect to bupropion
Concomitant therapy with bupropion may lead to a significant loss of [123I]FP-CIT binding and might result in false positive diagnosis of degenerative parkinsonism
Summary
The diagnosis of parkinsonian syndromes in patients suffering from severe depression can be challenging. Several drugs have been identified, occasionally patients and physicians are not aware that these drugs ought to be paused prior to [123I]FP-CIT-SPECT imaging This results either in prolonging the diagnostic procedures or, if not considered by specialists, even in imprecise diagnosis. In the course of her subjective cognitive decline, the patient exhibited a total score of 28/30 at the MiniMental State Examination (MMSE) (10) and of 15/18 at the DemTect (11) representing values within the normal range She suffered from psychomotor slowing, loss of interest and pleasure affecting her hobbies and most activities including the necessary daily routine, as well as delusions and hallucinations. Under a treatment regimen including tranylcypromine 50 mg, mirtazapine 30 mg, clozapine 100 mg, aripiprazole 10 mg, and clonazepam 2 mg/die that was accompanied by regular psychotherapeutic-, physiotherapeutic and ergotherapeutic support, a remarkable reduction of her depressive and psychotic symptoms was achieved. Continuing the abovementioned psychopharmacotherapy she was subsequently treated as outpatient and received psychosocial support at home
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