Severe Bruising as an Adverse Event: Chocolate or Fluvoxamine? Case Report

A 48-year old female inpatient was treated with fluvoxamine for anxiety disorder. There was no history of dysfunction of haemostasis and the routinely controlled INR and blood platelet count were normal. Thirty-one days after onset of therapy with a daily dose of 200mg fluvoxamine, severe bruising was observed on both legs for the first time. Therapy was discontinued 10 days later and no further haematomas were observed over the following week. During this period the patient suffered from pruritus, which led to scratching without alteration of the skin surface. Later, 10 days after cessation of fluvoxamine therapy, a provocation-test with self-scratching of the same intensity failed to produce further haematomas and examination of platelet function was normal. The patient was prescribed the MAOI, moclobemide with success and discharged 2 weeks later. Approximately 4 weeks after discharge, on a daily dose of 375mg moclobemide, the patient again noticed haematomas on both legs after scratching during night. Further investigation showed that the patient had consumed a number of chocolate-bars the evening before, as she had during hospitalisation.

There is a known correlation between platelet function and SSRIs, but not MAOIs. Furthermore collagen-induced platelet aggregation is inhibited by flavonoids in cocoa, e.g. in dark chocolate. This well documented case will be presented and the pathophysiological mechanism (SSRI, MAOI, platelets, cocoa) discussed.