A case of severe parkinsonism associated with short-term treatment with milnacipran

A 51-year-old woman became depressed following the death of her father-in-law. She was given 50 mg of milnacipran a day. One week after starting milnacipran, she developed parkinsonism. The milnacipran was increased to 100 mg/d, resulting in a situation where her symptoms of parkinsonism and depression worsened, which was associated with the reduction of 125I-meta-iodobenzylguanidine (MIBG) uptake. Three hundred milligrams of levodopa plus 30 mg of carbidopa was subsequently added to her medications. However, her symptoms still continued for 2 more weeks. Then the milnacipran was tapered, and she was given fluvoxamine with levodopa plus carbidopa. The parkinsonism and the depression gradually improved within 1 month after starting the regimen of fluvoxamine. The MIBG uptake also recovered (Heart to Lung ratio, 2.1) within 2 months. To our knowledge, this is the second reported case of parkinsonism associated with the use of serotonin noradrenaline reuptake inhibitor. This case showed a transient reduction of MIBG uptake associated with the parkinsonism and depression. Clinicians should be aware that serotonin noradrenaline reuptake inhibitors as well as selective serotonin reuptake inhibitors can cause parkinsonism.