A case of akathisia induced by escitalopram: case report & review of literature.

Although cases of Selective Serotonin Reuptake Inhibitor (SSRI) induced akathisia have often been reported in literature, this adverse effect has not adequately been mentioned in major pharmacology textbooks. As a result, SSRIinduced akathisia is very frequently under-recognized. A review of literature showed that almost all frequently used SSRIs such as Fluvoxamine, Fluoxetine, Sertraline, Citalopram have been reported to be causing akathisia. SSRI-induced restless legs syndrome and movement disorders have also been reported. However, Escitalopram-induced akathisia is rare. In our review of literature, we could find only one single case of Escitalopram-induced severe akathisia. And this specific SSRI drug has rarely been implicated with occurrence of restless legs syndrome and extra-pyramidal side-effects like dytonia etc. Here, we present a case of Escitalopram-induced severe akathisia - a 53year old female, who had developed severe akathisia after taking Escitalopram for a few days. According to the Barnes Akathisia Rating Scale (BARS), her Global Clinical Assessment of Akathisia Score was 5 i.e. severe akathisia. As per Naronjo Adverse Drug Reaction Scale the probability of association of this adverse reaction with Escitalopram was 7 (i.e. probable). Her symptoms continued in spite of prompt discontinuation of the drug. But, she improved rapidly with the use of Propranolol and Clonazepam. On the last follow-up, she was free from any symptoms. As new generation antidepressants are rarely associated with extra-pyramidal symptoms, the recognition of such adverse effects requires a high index of suspicion. Early recognition of the symptoms and discontinuation of the offending agent along with supportive therapy like a short course of benzodiazepines, beta-adrenergic antagonists or anticholinergics may rapidly relieve the patient from this distressing symptom.

Cutaneous metastasis in cancer of the uterine cervix: A case report and review of the literature.

Carcinoma of the uterine cervix is a common neoplasm among Indian women; in fact, it is the commonest malignancy among rural Indian women. Uterine cervical cancer spreads mainly to the regional lymph nodes, with distant metastasis rarely occurring. Major sites of distant metastasis are lung, bone, and liver. Skin metastasis from carcinoma of the uterine cervix is a very rare event. The reported incidence ranges from 0.1 to 2%. Here we describe a 60-year-old woman with cervical cancer who developed metastatic lesions on the lower abdominal wall and also over the inner aspects of thigh.

A comparison of dose distribution from Manchester-style and Fletcher-style intracavitary brachytherapy applicator systems in cervical cancer.

PURPOSE: During intracavitary brachytherapy (ICBT) for cervical cancer, the choice of applicator system remains rather arbitrary. However, as the applicator geometry may play an important role in dose distribution, thereby improving the therapeutic ratio, this study was conducted to compare the Manchester-style and Fletcher-style applicator systems. MATERIAL AND METHODS: After completion of EBRT, 22 patients with cervical cancer (stage IIA-IIIB) underwent intracavitary brachytherapy. Two different types of applicators: Manchester-style and Fletcher-style were used for each patient for alternate insertions. The purpose was to compare the dose distribution obtained when two different applicators were applied to the same patient. CT based computerized treatment planning was done and dose was prescribed to point A. After optimization, height, width and thickness of the 100% isodose curve, as well as the 100% isodose volume were noted. Dose received by the urinary bladder and rectum were noted. RESULTS: The 100% isodose volume and its maximum width were significantly greater (P value < 0.0001 in both occasions) when Manchester-style applicator was used. However, the dose received by 0.1 cc, 1.0 cc and 2.0 cc of the urinary bladder were all significantly greater (P value < 0.0001) with the Manchester-style applicator. No significant difference was found in rectal doses. CONCLUSIONS: The larger 100% isodose volume, as well as the greater width achieved with the use of Manchester-style applicator can be helpful in circumstances where the tumour is large in size. However, this must be balanced against the increased dose received by the urinary bladder.

Late nodal metastasis in early-stage node-negative oral cavity cancers after successful sole interstitial brachytherapy: an institutional experience of 42 cases in India.

PURPOSES: Brachytherapy, either alone or in combination with external irradiation, is a useful organ-preserving approach in the treatment of primary head and neck cancers. Treatment of regional nodal drainage area is not warranted in early-stage oral cavity cancers because T1N0 oral cavity cancers have less than 20% likelihood of nodal spread. We reviewed the records of interstitial brachytherapy cases of oral cavity cancers in our brachytherapy unit to assess the clinical outcome of the patients treated. METHODS AND MATERIALS: We tried to correlate the clinical outcome of the disease with different predictive factors for treatment outcome and to analyze statistically the role of these factors. RESULTS: Cases treated with combined external irradiation with interstitial brachytherapy included higher T stage, with greater risk for nodal spread, though initially node negative. As these were treated with microscopic dose for nodal clinical target volume, nodal recurrence was fewer (18.5%). On the contrary, although the early-stage (T1N0) oral cavity cancers that were treated with brachytherapy alone had initially a less than 20% chance of nodal metastasis, there was an increased risk up to 80% for late nodal metastasis after treatment. Tumor thickness >6mm (p=0.044) and need for a multiplanar implant (p=0.008) were found to be statistically significant risk factors for nodal recurrence. Other factors like high-grade tumors, ulcero-infiltrative lesions, implant of mobile tongue, and low hemoglobin, though relevant, were not found to be statistically significant. CONCLUSIONS: We recommend prophylactic nodal irradiation in addition to brachytherapy even for early-stage oral cancers treated with interstitial brachytherapy. Furthermore, the invasive procedure of interstitial brachytherapy causing a disruption of body's physiologic barrier to localize the disease is itself a probable risk factor for late nodal recurrence. Whether this, apart from the poor prognostic factors, causes increased chance of spread of a localized disease needs to be evaluated by a large prospective randomized study. This is needed to find out exactly the scenario where exclusive brachytherapy will be appropriate for treatment of early-stage oral cavity cancers.