Letters
ment, the patient was started on fluoxetine. After two days, a two-minute rhythm strip revealed a decrease in the number of PVCs. Holter monitor was repeated at five days and was read as unchanged from the pre-fluoxetine study. Another Holter ob· tained two weeks after initiation of fluoxetine again revealed no change from the prefluoxetine Holter. Cardiology eventually recommended addition of Procaine SR to treat the patient's underlying cardiac arrhythmias. The patient's depressive symptoms began to respond and he no longer revealed psychomotor retardation, sleep disturbance, appetite disturbance, or suicidal ideation. The patient became less with· drawn and was eventually discharged to home.
Mr. D's depressive symptoms improved on tluoxetine. and he exhibited no changes in his underlying cardiac arrhythmias on several Holter strips. Trazodone has been found to be associated with increased ventricular irritability; therefore. it was discontinued in this patient. 4 The traditional TCAs, with their quinidinelike effect, would have been a good choice for an antidepressant; however. because of the patient's history of multiple suicide attempts using TCAs. the decision was made to use tluoxetine. 2 Fluoxetine proved a good choice because of its low risk of being used to commit suicide and its lack of effect on cardiac rhythm. J5 Thus far. no studies have looked at tluoxetine use in patients with underlying cardiac disease. We believe this is the first reponed instance of use of tluoxetine in a patient with underlying cardiac arrhythmias. Further controlled studies of tluoxetine in patients with cardiac disease should be performed as we look for antidepressants for this important patient group. Michael N. zarzar, M.D. Richard S. Kingsley, M.D. Department of Psychiatry Medical University of South Carolina Charleston. South Carolina References I. Cohn J8. Wilcox C: A comparison of nuoxeline. imipra· mine, and placebo in patients wilh major depression disorder. J Cli" Psrchiatrr 46:26--31. 1985 2. Glassman AH. Bigger JT: Cardiovascular effect of therapeutic doses of tricyclic antidepressant. Arch Gen Psychiatry 38:815-820.1981
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3. Fisch C: Effect of nuoxeline on the electrocardiogram. J CIi" Psychiatry 46:42-44,1985 4. Janowsky D, Curtis G. Zisook S, et al: Ventricular arrhythymias possibly aggravated by trazodone. Am J Psychiatry 140:796--797. 1983 5. Wernicke JF: The side effeci profile and safety of nuoxeline. J Cli" Psychiatry 46:59--67.1985
Acute Laryngeal Dystonic Reactions SIR: I was very pleased to see the paper by Drs. Koek and Pi J featured in a recent issue of Psychosomatics. It brought to mind an on-call experience in July of my PGY-II residency in psychiatry. I received a stat page to one of the several units I was covering at the local veterans hospital. When I arrived on the unit. I found a young white male in his late 20s with dystonia of the head and neck and marked respiratory stridor with mild cyanosis of his lips. I was told that he had received his evening dose of haloperidol and had complained of muscle stiffness shortly thereafter. He had received 25 mg of diphenhydramine po approximately 30 minutes before I was called. Over that period. he had developed difficulty breathing. He responded promptly to 50 mg diphenhydramine via intravenous push. Upon recovery, he reported that this had happened to him once before. in a previous hospitalization, and that he had been left "to gut it out" after diphenhydramine intramuscularly produced no relief since the doctor did not believe he was having true respiratory distress. Fortunately. as an intern I was trained that laryngeal dystonic reactions can occur and must be treated intravenously. Since then. however. I have heard or read little about this dramatic, life-threatening, and easily treatable reaction. I hope that the article by Koek and Pi will become required reading in all residency curricula. Cynthia B. Stevens, M.D. George Washington University Medical Center Washington, D.C. References I. Koek RJ. Pi EH: Acute laryngeal dystonic reactions 10 neuroleptics: a review. Psychosomatics 30:359-364, 1989
PSYCHOSOMATICS
ment, the patient was started on fluoxetine. After two days, a two-minute rhythm strip revealed a decrease in the number of PVCs. Holter monitor was repeated at five days and was read as unchanged from the pre-fluoxetine study. Another Holter ob· tained two weeks after initiation of fluoxetine again revealed no change from the prefluoxetine Holter. Cardiology eventually recommended addition of Procaine SR to treat the patient's underlying cardiac arrhythmias. The patient's depressive symptoms began to respond and he no longer revealed psychomotor retardation, sleep disturbance, appetite disturbance, or suicidal ideation. The patient became less with· drawn and was eventually discharged to home.
Mr. D's depressive symptoms improved on tluoxetine. and he exhibited no changes in his underlying cardiac arrhythmias on several Holter strips. Trazodone has been found to be associated with increased ventricular irritability; therefore. it was discontinued in this patient. 4 The traditional TCAs, with their quinidinelike effect, would have been a good choice for an antidepressant; however. because of the patient's history of multiple suicide attempts using TCAs. the decision was made to use tluoxetine. 2 Fluoxetine proved a good choice because of its low risk of being used to commit suicide and its lack of effect on cardiac rhythm. J5 Thus far. no studies have looked at tluoxetine use in patients with underlying cardiac disease. We believe this is the first reponed instance of use of tluoxetine in a patient with underlying cardiac arrhythmias. Further controlled studies of tluoxetine in patients with cardiac disease should be performed as we look for antidepressants for this important patient group. Michael N. zarzar, M.D. Richard S. Kingsley, M.D. Department of Psychiatry Medical University of South Carolina Charleston. South Carolina References I. Cohn J8. Wilcox C: A comparison of nuoxeline. imipra· mine, and placebo in patients wilh major depression disorder. J Cli" Psrchiatrr 46:26--31. 1985 2. Glassman AH. Bigger JT: Cardiovascular effect of therapeutic doses of tricyclic antidepressant. Arch Gen Psychiatry 38:815-820.1981
236
3. Fisch C: Effect of nuoxeline on the electrocardiogram. J CIi" Psychiatry 46:42-44,1985 4. Janowsky D, Curtis G. Zisook S, et al: Ventricular arrhythymias possibly aggravated by trazodone. Am J Psychiatry 140:796--797. 1983 5. Wernicke JF: The side effeci profile and safety of nuoxeline. J Cli" Psychiatry 46:59--67.1985
Acute Laryngeal Dystonic Reactions SIR: I was very pleased to see the paper by Drs. Koek and Pi J featured in a recent issue of Psychosomatics. It brought to mind an on-call experience in July of my PGY-II residency in psychiatry. I received a stat page to one of the several units I was covering at the local veterans hospital. When I arrived on the unit. I found a young white male in his late 20s with dystonia of the head and neck and marked respiratory stridor with mild cyanosis of his lips. I was told that he had received his evening dose of haloperidol and had complained of muscle stiffness shortly thereafter. He had received 25 mg of diphenhydramine po approximately 30 minutes before I was called. Over that period. he had developed difficulty breathing. He responded promptly to 50 mg diphenhydramine via intravenous push. Upon recovery, he reported that this had happened to him once before. in a previous hospitalization, and that he had been left "to gut it out" after diphenhydramine intramuscularly produced no relief since the doctor did not believe he was having true respiratory distress. Fortunately. as an intern I was trained that laryngeal dystonic reactions can occur and must be treated intravenously. Since then. however. I have heard or read little about this dramatic, life-threatening, and easily treatable reaction. I hope that the article by Koek and Pi will become required reading in all residency curricula. Cynthia B. Stevens, M.D. George Washington University Medical Center Washington, D.C. References I. Koek RJ. Pi EH: Acute laryngeal dystonic reactions 10 neuroleptics: a review. Psychosomatics 30:359-364, 1989
PSYCHOSOMATICS
