"My life has become a story of sufferings and my body is the housing for all the possible diseases" is the way Mr. AD would express his anguish and frustration of suffering from a major depressive episode with multiple somatic complaints whose cause could not be ascribed ascertained to any of the body systems in spite of two files full of investigation reports. He used to feel low throughout the day and had lost his interest in pleasurable activities like watching TV, chatting with others or even playing with his newly born daughter. He had difficulty in concentrating and his appetite had decreased. Although he never contemplated suicide, he found his life meaningless. The patient also had multiple somatic complaints in the form of a vague aching sensation in his head, chest and generalized myalgia.
He had been having these problems for over a year and had been on tri cyclic antidepressants (TCA), namely amitryptiline up to 200 mg/ day, nortryptiline up to 175 mg/ day and selective serotonergic reuptake inhibitors (SSRI) group, namely fluoxetine up to 60 mg/ day and escitalopram up to 20 mg/ day, as the patient had chosen pharmacotherapy at the beginning of the treatment. There was only minimal improvement in his symptoms with the medicines.
Following the introduction of duloxetine in the local market, the treating team decided to try it as it acts on both, the noradrenergic and serotonergic systems. He was put on 20 mg/day and the dose was gradually increased to 40 mg/day in two divided doses after two weeks. The patient didn't report any significant side-effect apart from a mild exacerbation of his epigastric pain that responded well to a proton pump blocker that he took for four days. After 10 days of hiking the dose to 40 mg/day he developed bleeding from the gums. He noticed traces of blood in his saliva in the morning while spitting. His gums had become raw and blood oozed from their surface. The bleeding was minimal but was alarming to the patient and his family and they returned for review a week after the onset of bleeding. There was no change in his dietary habits or any new drug intake during this time. He did not consume alcohol and never had any significant medical illness. He never had any problem with his teeth or gums and had never been to a dentist before.
A dental referral did not reveal any local cause of the bleeding. The patient was not taking any other concomitant medications at the time of the development of this side-effect. His bleeding time, clotting time, platelet count, activated partial thromboplastin time (APTT), prothrombin time (PT) were all within the normal range. Routine hemogram, renal and liver function tests were also within the normal range. Considering the temporal correlation of the bleeding to duloxetine, the drug was withdrawn. Over the next one week the bleeding from his gums resolved and the patient was continued on tricyclic antidepressants. The patient is currently in partial remission of depression and has not reported any further episodes of gum bleeding. A score of four was obtained on Naranjo's algorithm for adverse drug reaction which implicated duloxetine as a possible cause of the event.
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