Ecchymosis Related to Paroxetine and Sertraline

Selective serotonin reuptake inhibitors (SSRIs) are widely used for treating depressive and anxiety disorders. Although SSRIs have a safety profile, some authors have reported that they associated with an increased risk of bleeding events. We report a case of paroxetineand sertraline-associated ecchymoses in a patient with depression.


INTRODUCTION
Selective serotonin reuptake inhibitors (SSRIs) are widely used for treating depressive and anxiety disorders.Although SSRIs have a safety profile, some authors have reported that this class of antidepressantis associated with an increased risk of bleeding events (1,2).Most of these cases have been related to largerchances of gastrointestinal bleeding (2).There have been few reports of ecchymoses related to SSRI use (3).We report a case of paroxetine-and sertraline-associated ecchymoses in a patient with depression.

CASE
A 35-year-old female was admitted to the psychiatric outpatient clinic with symptoms of depressed mood, anhedonia, increased sleep and appetite, psychomotor slowing, and reduced ability to concentrate during the past four weeks.The patient had a history of duloxetine use at 60 mg/day due to a diagnosis of major depressive episode for the previous year.However, she had discontinued the duloxetine after only two months because of nausea, despite the fact that her symptoms had improved since she had begun taking the medication.A psychiatric interview using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, demonstrated a current major depressive episode.The patient was started on paroxetine 15 mg/day.Two weeks after this treatment was initiated, she noted the ecchymoses on her legs and hips.She had no previous history of abnormal bleeding or any systemic illness and denied trauma or any medications.Hematological investigations, including a complete coagulation profile, were normal.The possibility of paroxetine-related ecchymoses was suggested.The drug was discontinued, and her symptoms disappeared within two weeks, at which time the patient was prescribed sertraline 50 mg/day.Twenty days later, ecchymoses appeared on her legs again.Sertraline Ecchymoses with paroxetine and sertraline 357 was discontinued,and the patient returned for an evaluation five days later.She was given escitalopram 10mg/ day, and for the past four months, there has been no recurrence of the ecchymoses.

DISCUSSION
Abnormal bleeding associated with SSRI treatment has been reported in increasing numbers of patients in recent years (2-4).Both antidepressants described in this report are frequently used worldwide, but the side effect of ecchymoses is very rare.This case was diagnosed as ecchymoses associated with paroxetine and sertraline.Other causes were excluded in this case, and the patient's symptoms resolved following discontinuation of the drug.Thus, the evidence strongly supported a drug-related adverse reaction.The precise mechanism underlying the abnormal bleeding presented in this report is currently unknown.Several mechanisms could have been responsible for the ecchymoses resulting from selective serotonin reuptake inhibitors.SSRIs act on the serotonin transporter located on platelet cell mem¬branes (5).Regular use of SSRIs leads to a decrease in serotonin uptake into platelets.Serotonin has been associated with platelet aggregation, which may produce a bleeding tendency (6,7).In addition, hyperserotonemia can cause skin and mucous membrane lesions, such as dilated capillaries or telangiectasia, whichmay cause bleeding even in the absence ofany hemostatic defect (8).
It has been reported that antidepressants with a high degree of inhibition of serotonin reuptake were associated with a 2.6-fold increased risk of bleeding events compared with antidepressants that havea low degree of serotonin reuptake inhibition (1).Paroxetine, fluoxetine, and sertraline, the SSRIs with the highest degree of serotonin reuptake inhibition, are more commonly associated with modifications of hemostatic markers and abnormal bleeding (9).
It is important for clinicians to be aware of increased risk of bleeding with use of SSRIs.In conclusion, an increased risk of bleeding can occur in patients treated with SSRIs.Physicians and psychiatrists should be mindful of this possibility while evaluating patients takingSS-RIs who present withbleeding problems.