Is there an association between sertraline (selective serotonin reuptake inhibitor) consumption, lymphadenitis tuberculosis (TB), and acute left arm pain with limited shoulder mobility in a young female patient?

Acute Left Shoulder Pain in Patient on Sertraline with TB Lymphadenitis

There is no direct pharmacological association between sertraline use and acute shoulder pain with limited mobility. The clinical presentation suggests a musculoskeletal or neurological etiology that requires urgent evaluation, particularly given the context of tuberculous lymphadenitis which can cause nerve compression or skeletal involvement.

Primary Clinical Considerations

Tuberculosis-Related Complications

• TB lymphadenitis can extend beyond lymph nodes to involve adjacent structures, including the brachial plexus, cervical spine, or shoulder joint itself. 1
• Tuberculous involvement of the shoulder joint (tuberculous arthritis) or adjacent bone (tuberculous osteomyelitis) presents with acute pain and severely limited range of motion 1
• Enlarged tuberculous lymph nodes in the supraclavicular or axillary regions can compress the brachial plexus, causing referred pain to the shoulder and arm with movement limitation 1
• Immediate imaging (MRI of the shoulder and cervical spine) is essential to rule out skeletal TB, septic arthritis, or nerve compression from lymphadenopathy 1

Sertraline Safety Profile

• Sertraline is not associated with musculoskeletal pain, joint pain, or movement disorders as adverse effects 2, 3, 4
• The most common adverse effects of sertraline include gastrointestinal disturbances (nausea, diarrhea), headache, insomnia, somnolence, and sexual dysfunction—none of which explain acute shoulder pain 2, 3
• Sertraline has minimal anticholinergic activity and is essentially devoid of effects that would cause acute musculoskeletal symptoms 3

Differential Diagnosis to Evaluate

Musculoskeletal Causes

• Septic arthritis of the glenohumeral joint (particularly relevant given immunosuppression from TB and potential steroid use for TB treatment)
• Tuberculous arthritis of the shoulder joint 1
• Rotator cuff pathology (tear, tendinitis)
• Adhesive capsulitis (frozen shoulder)

Neurological Causes

• Brachial plexus compression from enlarged tuberculous lymph nodes (cervical, supraclavicular, or axillary) 1
• Cervical radiculopathy
• Peripheral neuropathy (though sertraline can be used to treat neuropathic pain, it does not cause it) 5

Infectious/Inflammatory Causes

• Extension of TB lymphadenitis to involve the shoulder joint, bursa, or adjacent bone 1
• Osteomyelitis of the proximal humerus or scapula
• Septic bursitis

Immediate Management Algorithm

1. Obtain detailed physical examination focusing on:

   • Palpable lymphadenopathy in cervical, supraclavicular, and axillary regions
   • Shoulder joint effusion, warmth, or erythema
   • Neurological examination of the upper extremity (strength, sensation, reflexes)
   • Range of motion testing (active and passive)
   • Cervical spine examination 1

2. Order urgent imaging:

   • Plain radiographs of the shoulder (AP, lateral, axillary views) to assess for bone destruction, joint space narrowing, or soft tissue swelling
   • MRI of the shoulder and cervical spine with contrast to evaluate for tuberculous involvement, septic arthritis, or nerve compression 1
   • Chest radiograph to assess pulmonary TB status 1

3. Laboratory evaluation:

   • Complete blood count, erythrocyte sedimentation rate, C-reactive protein
   • Blood cultures if septic arthritis suspected
   • Consider arthrocentesis if joint effusion present (synovial fluid analysis, culture, acid-fast bacilli smear and culture) 1

Pain Management Considerations

Appropriate Analgesics with Sertraline

• Acetaminophen is safe and appropriate as initial therapy (up to 4g daily, though monitor blood pressure if hypertensive) 5
• Topical agents (lidocaine, diclofenac) are safe alternatives 5
• Avoid NSAIDs if possible due to gastrointestinal bleeding risk when combined with sertraline (SSRIs increase bleeding risk) 5
• Gabapentin or pregabalin can be safely co-administered with sertraline if neuropathic pain is suspected from nerve compression 6
• Low-dose opioids (immediate-release formulations) are safe with sertraline for severe acute pain 5

Critical Drug Interaction Considerations

• Sertraline does not interact with pregabalin, gabapentin, or acetaminophen 6
• True serotonin syndrome risk only occurs when sertraline is combined with other serotonergic agents (MAOIs, other SSRIs/SNRIs, tramadol, trazodone)—not with standard analgesics 6, 7
• Sertraline has minimal effect on cytochrome P450 enzymes (mild CYP2D6 inhibition only), making drug interactions uncommon 4

Common Pitfalls to Avoid

• Do not attribute the shoulder pain to sertraline without thorough evaluation—this medication does not cause musculoskeletal symptoms 2, 3, 4
• Do not overlook tuberculous involvement of the shoulder joint or adjacent structures—extrapulmonary TB can affect any organ system, particularly in immunocompromised states 1
• Do not prescribe NSAIDs without considering the increased bleeding risk when combined with SSRIs like sertraline 5
• Do not delay imaging if neurological symptoms are present—brachial plexus compression requires urgent intervention 1