Can a brain tumor cause tingling sensations in an adult patient with a history of anxiety or depression, who previously took escitalopram (citalopram) and experienced potential serotonin syndrome, now presenting 3 months after discontinuing the medication?

Can a Brain Tumor Cause Tingling Sensations in This Clinical Context?

A brain tumor is an unlikely cause of isolated tingling sensations occurring 3 months after discontinuing escitalopram in a patient with anxiety/depression history, as these symptoms are far more consistent with SSRI discontinuation syndrome or anxiety-related physical manifestations.

Why Brain Tumor is Unlikely

Tingling (paresthesias) from anxiety and SSRI discontinuation is well-documented and common, whereas isolated paresthesias from a brain tumor would typically present with additional focal neurological deficits. 1, 2

Anxiety Produces Real Physical Symptoms

• Paresthesias (numbness or tingling) are recognized physical manifestations of anxiety disorders by multiple guideline organizations 2, 3
• Anxiety causes genuine physiological pathology through neuroendocrine pathways, not imagined complaints 2, 3
• Other neurological symptoms from anxiety include dizziness and feeling lightheaded 2

SSRI Discontinuation Syndrome Explains the Timeline

A discontinuation syndrome characterized by sensory disturbances and paresthesias has been reported following missed doses or acute discontinuation of SSRIs, particularly with shorter-acting agents like escitalopram. 1

• The 3-month timeline since stopping escitalopram fits with prolonged discontinuation effects 1
• Discontinuation syndrome includes dizziness, vertigo, sensory disturbances, and paresthesias alongside other symptoms like fatigue, myalgias, headaches, nausea, and anxiety 1
• Escitalopram/citalopram, while having lower propensity for drug interactions, can still cause discontinuation syndrome 1

Critical Diagnostic Approach

Rule Out Medical Causes First

Before attributing tingling to anxiety or medication effects, you must exclude medical conditions including thyroid disorders, electrolyte imbalances, and peripheral neuropathy. 2, 3

• Complete thyroid function tests and glucose if suggested by clinical presentation 2
• Check electrolytes, particularly if there are other systemic symptoms 3
• Assess for delirium from infection or metabolic derangement 3

When to Consider Neuroimaging

A brain tumor would warrant consideration if the patient has:

• Progressive focal neurological deficits (weakness, visual changes, speech difficulties) 2
• New-onset seizures 2
• Severe headaches with specific patterns (worse in morning, with vomiting) 2
• Altered mental status beyond what anxiety explains 3

Isolated paresthesias without these red flags do not require urgent neuroimaging. 2, 3

Recommended Management Algorithm

Step 1: Comprehensive Medical Workup (Days 1-3)

• Obtain thyroid function tests, complete metabolic panel, and glucose 2
• Review all current medications and supplements for serotonergic agents 1
• Assess for signs of serotonin syndrome recurrence: hyperreflexia, clonus, muscle rigidity, autonomic instability 1

Step 2: Assess Anxiety Severity (Day 1)

• Use GAD-7 to quantify anxiety; scores ≥10 require comprehensive evaluation 2, 3
• Use Hospital Anxiety and Depression Scale (HADS), which excludes somatic symptoms that may be confounded by medical illness 2, 3
• Screen for depression with PHQ-9, as approximately 31% of patients with anxiety disorders also have major depressive disorder 2, 3

Step 3: Treatment Based on Findings

If medical workup is negative and anxiety symptoms are prominent:

• First-line treatment is SSRIs (such as sertraline, NOT escitalopram given prior issues) or cognitive behavioral therapy 2, 3
• Educate about the physiological process of anxiety, breathing techniques, progressive muscle relaxation, and grounding strategies 2
• Regular cardiovascular exercise is recommended 2

If symptoms persist despite anxiety treatment after 8 weeks:

• Alter the treatment course by adding psychological or pharmacologic intervention 1
• Consider referral to neurology only if new focal findings develop 2, 3

Critical Pitfalls to Avoid

Do not dismiss physical symptoms as "just anxiety" without proper medical workup, as real medical conditions can coexist with anxiety. 2, 3

• The relationship between anxiety and physical symptoms is bidirectional—anxiety can contribute to physical illness, result from physical illness, or be a reaction to it 2
• Do not overlook the common comorbidity between depression and anxiety 2, 3
• Avoid reflexively ordering brain imaging for isolated sensory symptoms without neurological red flags, as this increases healthcare costs without improving outcomes 2, 3

Given the history of potential serotonin syndrome with escitalopram, exercise extreme caution if restarting any serotonergic medication. 1, 4, 5, 6

• Start any new serotonergic drug at a low dose and increase slowly 1
• Monitor closely for symptoms in the first 24-48 hours after dosage changes 1
• The careless readministration of SSRIs is particularly harmful in at-risk patients 6