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A case of early multiple system atrophy unveiled by antidepressant administration

Affective symptoms can be the initial manifestation of Parkinsonism. In some cases, it is difficult to distinguish dull facial expression and psychomotor retardation associated with depression from the masked face and bradykinesia seen in Parkinsonism. We here report a patient with anxious depression who, after selective serotonin reuptake inhibitor (SSRI) treatment, developed progressively obvious extrapyramidal symptoms (EPS). Multiple system atrophy (MSA) was later confirmed. A 52-year-old female patient (BS) with no personal or family history of psychiatric illness presented with depressed mood, anxiety, multiple somatic discomforts (dyspnoea, chest tightness, palpitations and burning sensation of the limbs), insomnia, poor appetite and weight loss of 7 kg in 4 months (47.5 kg at evaluation). BS visited several psychiatric clinics and was treated with multiple different SSRIs, including fluoxetine, sertraline and escitalopram. She was admitted briefly to the psychiatric ward on one occasion. When taking SSRIs, she displayed akathisia and other EPS, including aggravated psychomotor retardation, rigidity, distal tremor and unsteady gait. The EPS always improved with discontinuation of antidepressants and hindered her from using SSRIs for more than 1 week. Her anxiety and depression were not alleviated. The EPS occurring with SSRI therapy was progressively more evident over time. BS visited our clinic after approximately 6 months of doctor shopping. Our assessment revealed that her respective scores of Hamilton Rating Scale for Depression (HAM-D) and Hamilton Rating Scale for Anxiety (HAM-A) were 30 and 40 (1,2). Duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), was prescribed to BS for several days, but again was 0 0.5 1.5 1.8 2.1 Left