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Serotonin Syndrome Associated With Citalopram and Meperidine
Letters Clinician Educator Depts. of Psychiatry and Medicine Brown Univ. Medical School Providence, RI
Reference
1. Cervantes AN, Rabins PVR, Slavney PR: Onset of schizophrenia at age 100. Psychosomatics 2006; 47:356–359
Mastectomy Resulting From Factitious Disorder TO THE EDITOR: Mastectomy as a direct result of factitious disorder (termed “Munchausen syndrome” in its most severe form) is distinctly rare, with only one report in English.1 In that case, reported in Psychosomatics, a woman misled surgeons into believing she had a profound family history of breast and ovarian cancer, a claim they did not attempt to corroborate, and they proceeded with a prophylactic bilateral radical mastectomy. The patient declined psychiatric care and was lost to follow-up. As a cautionary tale, we present another woman whose false claims of a history of familial breast and ovarian cancer led to an unwarranted bilateral mastectomy. Case Report “Ms. A,” a 28-year-old single nurse with a history of unexplained illness and manufactured crises, presented to surgeons with a factitious report of breast and ovarian cancer in numerous relatives, including her twin sister. She insisted on a prophylactic bilateral mastectomy; it was performed, in part, because there was the suggestion of a lump in one breast, although a mammogram had been negative. The patient failed to appear for a scheduled biopsy, but the surgery proceeded nevertheless. Immediately after the procedure, the doctor spoke with Ms. A’s parents and Psychosomatics 48:4, July-August 2007
learned that the twin had always been in good health. It was also determined that the report of a family history of malignancy was spurious, and that the patient had a history of pathological lying about her background and about illness. Three weeks post-surgery, the patient suddenly developed a wound infection, one of several suspicious infections she had developed over the years. She has moved back with her parents and, unlike most factitious-disorder patients, is receiving psychiatric care. She has indicated that she had always believed that her twin got more attention from their parents and that her lies were intended as a diversion and a form of retaliation. Discussion Several lapses led to the unwarranted surgery. These included a failure to obtain any outside records, to insist upon a biopsy, consult with family members, and pursue genetic testing. However, it is the ability of the factitious-disorder patient to convince the practitioner to depart from standard clinical practices that is a root cause of the morbidity and mortality risks associated with the disorder. Factors that might raise suspicion in such gynecological cases, for instance, are the patient’s not knowing about the cancer treatments received by close relatives, claiming primary cancers in both breasts, showing an unusual disease pattern, offering other medical complaints determined to be false, giving a history that cannot be corroborated through family reports or outside records, and overeagerly pursuing surgery. This case highlights the fact that the consequences of factitious disorder can be irreversible and iatrogenic. Although it may seem counterintuitive, in at least one case, physicians were sued because they administered treatment based upon a fallacious his-
tory. (The case was settled for a dollar amount in six figures.)2 Marc D. Feldman, M.D. Dept. of Psychiatry and Behavioral Medicine James C. Hamilton, Ph.D. Dept. of Psychology Univ. of Alabama, Tuscaloosa, AL
References
1. Feldman MD: Prophylactic bilateral radical mastectomy resulting from factitious disorder. Psychosomatics 2001; 42:519–521 2. Lipsitt DR: The factitious patient who sues (letter). Am J Psychiatry 1986; 143:1482
Serotonin Syndrome Associated With Citalopram and Meperidine TO THE EDITOR: Serotonin syndrome (SS) is serious and poses a potentially life-threatening risk, resulting when two or more serotonin reuptake-inhibiting medications are used together. Although some agents are quickly recognized as serotonergic, others are less well-known. We describe a unique case of SS in a hospitalized patient when meperidine was added to a medication regimen that included citalopram. Case Report “Ms. C,” a 44-year-old woman who had had surgical resection of rectal cancer, was diagnosed with depression shortly after her cancer diagnosis. She was started on citalopram 20 mg by mouth (po) daily. Nine months later, she was admitted to surgery for debridement of the rectal wound. She was on the surgery ward when her depression significantly worsened. Psychiatry helped with the patient’s symptoms as per the requesting ward team; we provided psychotherapy and increased citalopram to 40 mg po daily. Her depression steadily improved 361
Letters over several weeks. Thus, it was a surprise when Ms. C. was found to be “behaving very oddly” one night. She was experiencing acute agitation, disorientation, paranoia, perceptual disturbances, and nausea. Simultaneously, she spiked a temperature of 39.1⬚C. Her systolic blood pressure was 161 mmHg, and her diastolic blood pressure was 86 mmHg. Respirations were 22 per minute, and heart rate was 112 beats per minute. The Psychiatry Dept. was not contacted that night because these symptoms were believed a typical part of her “psychiatric condition.” Her medical work-up included computed tomography (CT), ECG, and chest X-ray, all of which were normal. Physical examination uncovered a localized wound infection, and blood cultures revealed no growth after 5 days. Laboratory results included an elevated total white bloodcell count of 14,500 l/L, platelet count of 531,000 l/L, and hemoglobin and hematocrit of 13 g/dl and 39%, respectively. A complete metabolic panel was within normal limits. Review of her as-needed (prn) medications revealed hydromorphone 50 mg intravenously (IV) every 6 hours (q 6 hr.) for pain, hydrocodone bitartrate-acetaminophen 5 mg/500 mg po q 6 hr. for pain, and promethazine 12.5 mg IV q 6 hr. for nausea. For breakthrough pain, patient-controlled anesthesia with meperidine had been added before onset of the symptoms. The total parenteral dose of meperidine, over 8 hours, was 230 mg. Ms. C’s symptoms began within 10 hours of starting meperidine, and then stopped 12 hours after discontinuation. Once meperidine was stopped, no episodes occurred during the next 3 months. Gatifloxacin, for treatment of the wound infection, had been initiated 5 days before symptom onset and then continued for 5 more days, for a total 362
http://psy.psychiatryonline.org
10-day course. Other medications included zolpidem tartrate 10 mg before bedtime (hs), lansoprazole 30 mg twice daily (bid), subcutaneous enoxaparin sodium 30 mg twice daily (bid), and a fentanyl patch 50 mcg/hour every 72 hours. Discussion SS is a serious, potentially life-threatening condition resulting from hyperstimulation of 5-hydroxytriptamine (5HT) receptors. The diagnosis is based on Sternbach’s criteria.1 Three of the following must be satisfied: mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, or fever. Symptoms coincide with initiation of, addition of, or increase in dosage of a serotomimetic agent. Other etiologies are excluded. Finally, a neuroleptic agent should not have been initiated or increased in dosage before onset of signs and symptoms.1,2 Ms. C was on citalopram for 9 months, with a dose increase 5 weeks before symptom onset. Her symptoms began within 24 hours of meperidine administration, and she was confused, agitated, febrile, hypertensive, tachycardic, and tachypneic. These symptoms resolved 12 hours after meperidine was discontinued. A careful MEDLINE search, using keywords, “serotonin syndrome,” “citalopram,” “meperidine,” and “SSRI” found no reported cases of SS with citalopram and meperidine together. The literature did reveal reports with citalopram and other serotonergic agents,3 and serotonergic agents and meperidine,4 as well as meperidine and monoamine oxidase inhibitors.5 There was one case with fluoxetine and meperidine.6 Evidence suggests that fentanyl may possibly block serotonin reuptake.4,7 The patient’s other medications
have negligible affinity for the 5-HT receptor.7 Potential dangers, including SS, may occur when medically ill patients are prescribed serotonergic agents. Sometimes, medications like meperidine are not immediately identified as serotonergic, and are added to a patient’s regimen. There currently is no contraindication to their coadministration, and prescribers may not receive warnings about their simultaneous use. Because of their overall safety compared with older antidepressants, clinicians may underestimate the potential for SSRIs and newer serotonergic medications to cause serious morbidity. Serotonergic agents should only be used with meperidine-type analgesics when the benefits to the patient’s health outweigh the potential consequences. Evan M. Altman, D.O., Chief Resident Gail H. Manos, M.D., Training Director Dept. of Psychiatry, Naval Medical Center, Portsmouth, VA References
1. Sternbach H: The serotonin syndrome. Am J Psychiatry 1991; 148:705–713 2. Boyer EW, Shannon M: The serotonin syndrome. N Engl J Med 2005; 352:1112–1120 3. Mahlberg R, Kunz D, Sasse J, et al: Serotonin syndrome with tramadol and citalopram. Am J Psychiatry 2004; 161:1129 4. Giese SY: Serotonin syndrome: potential consequences of Meridia combined with Demerol or fentanyl. Plast Reconstr Surg 2001; 107:293–294 5. Latta KS, Ginsberg B, Barkin RL: Meperidine: a critical review. Am J Therapeut 2002; 9:53–68 6. Tissot TA: Probable meperidine-induced serotonin syndrome in a patient with a history of fluoxetine use. Anesthesiology. 2003; 98:1511–1512 7. Baldessarini RJ: Drugs and the treatment of psychiatric disorders: depression and anxiety disorders, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 10th Ed. Edited by Hardman JG,
Psychosomatics 48:4, July-August 2007
Letters Limbird LE. New York, McGraw-Hill, 2001, pp 456–460
Antibiomania and Ciprofloxacin-Induced Mania TO THE EDITOR: There have been increasing reports of mania associated with administration of antibiotics in patients without a previous history of bipolar disorder. The report by Bhalerao et al. (2006)1 of mania induced by ciprofloxacin is interesting, although it does not appear to be the first report of this association. Although Bhalerao et al.1 cite the article by Abouesh et al. on antibiomania,2 they do not report that the cited article describes 23 cases of ciprofloxacin-induced mania, 12 from the 1997 WHO database, and 11 from the FDA database. It appears that clarithromycin, fluoroquinolones (including ciprofloxacin and ofloxacin), and isoniazid, among antibiotic drugs, are most frequently associated with development of mania.2,3 These three antibiotics are attributed to 90% of all published cases of mania secondary to antibiotics— 66% of the cases in the WHO database and 85% of cases in the FDA database, respectively.2 It is thought that the mechanism of antibiotic-induced mania is related to GABA-antagonism, and there is some evidence that ciprofloxacin is a GABA-antagonist. Interestingly, four WHO-database patients (33%) and five of the FDAdatabase patients (45%) were also prescribed agents that are either known or suspected of causing manic symptoms.
Psychosomatics 48:4, July-August 2007
Similarly, three patients in the WHO database (25%) and two in the FDA database (18%) were concurrently taking mood-stabilizing agents (lithium, carbamazepine, and/or valproate). Applying the Naranjo adverse drug reactions (ADR) probability scale criteria4 to the case described by Bhalerao et al.,1 the manic episode appears, at most, only a “possible” (less likely than a “probable” or “definite”) reaction to ciprofloxacin. The patient described by Bhalerao et al.1 presented at admission with symptoms of anorexia and fatigue, and was possibly depressed. Ulcerative colitis,5 primary biliary cholangitis (and, specifically, fatigue in that condition), and treatment with sulfasalazine6 have all been associated with depression. It is not entirely clear whether sulfasalazine prescribed (potentially long-term) this patient was stopped along with other drugs on discharge. As Helzer et al.5 lament, despite the fact that more than one-quarter of ulcerative colitis patients have some diagnosable psychiatric illness, the occurrence of psychiatric disorder is rarely documented in their medical charts. Whether there were depressive symptoms before admission or not, this could well be a first episode of mania in a young man responding to antipsychotic treatment. It would be helpful to know whether he had a family history of bipolar disorder or any other psychiatric disorder. Interestingly, metronidazole coprescription, also relevant in this case,1 was also prescribed in several cases
(N⳱10) of antibiotic-induced mania.2 Although metronidazole was stopped before discharge, its contribution to the development of mania needs to be considered. The onset of agitation/violence occurred after discharge, but the onset of a milder, hypomanic episode might have been missed, possibly even contributing to the apparent “quick clinical improvement” on a medical ward. If that is true, any of the other drugs could easily have also been responsible for the manic symptoms. Niraj Ahuja, M.B.B.S., M.D., M.R.C.Psych. Adrian J. Lloyd, M.B.B.S., M.D., M.R.C.Psych. Wallsend Community Mental Health Team Sir G.B. Hunter Memorial Hospital, The Green, Wallsend, NE28 7PD, UK References
1. Bhalerao S, Talsky A, Hansen K, et al: Ciprofloxacin-induced manic episode. Psychosomatics 2006; 47:539–540 2. Abouesh A, Stone C, Hobbs WR: Antimicrobial-induced mania (antibiomania): a review of spontaneous reports. J Clin Psychopharmacol 2002; 22:71–81 3. (Anonymous): Mania induced by antimicrobial agents, mainly, isoniazid, clarithromycin, and fluoroquinolones. Prescrire Intl 2003; 12:183 4. Naranjo CA, Busto U, Sellers EM, et al: Method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30:239–245 5. Helzer JE, Stillings WA, Chammas S, et al: A controlled study of the association between ulcerative colitis and psychiatric diagnoses. Dig Dis Sci 1982; 27:513–518 6. Rebrov VG, Lukomskii MI: A case of depression in the treatment of nonspecific ulcerative colitis with sulfasalazine. Klin Med (Moscow) 1989; 67:106
363
Reference
1. Cervantes AN, Rabins PVR, Slavney PR: Onset of schizophrenia at age 100. Psychosomatics 2006; 47:356–359
Mastectomy Resulting From Factitious Disorder TO THE EDITOR: Mastectomy as a direct result of factitious disorder (termed “Munchausen syndrome” in its most severe form) is distinctly rare, with only one report in English.1 In that case, reported in Psychosomatics, a woman misled surgeons into believing she had a profound family history of breast and ovarian cancer, a claim they did not attempt to corroborate, and they proceeded with a prophylactic bilateral radical mastectomy. The patient declined psychiatric care and was lost to follow-up. As a cautionary tale, we present another woman whose false claims of a history of familial breast and ovarian cancer led to an unwarranted bilateral mastectomy. Case Report “Ms. A,” a 28-year-old single nurse with a history of unexplained illness and manufactured crises, presented to surgeons with a factitious report of breast and ovarian cancer in numerous relatives, including her twin sister. She insisted on a prophylactic bilateral mastectomy; it was performed, in part, because there was the suggestion of a lump in one breast, although a mammogram had been negative. The patient failed to appear for a scheduled biopsy, but the surgery proceeded nevertheless. Immediately after the procedure, the doctor spoke with Ms. A’s parents and Psychosomatics 48:4, July-August 2007
learned that the twin had always been in good health. It was also determined that the report of a family history of malignancy was spurious, and that the patient had a history of pathological lying about her background and about illness. Three weeks post-surgery, the patient suddenly developed a wound infection, one of several suspicious infections she had developed over the years. She has moved back with her parents and, unlike most factitious-disorder patients, is receiving psychiatric care. She has indicated that she had always believed that her twin got more attention from their parents and that her lies were intended as a diversion and a form of retaliation. Discussion Several lapses led to the unwarranted surgery. These included a failure to obtain any outside records, to insist upon a biopsy, consult with family members, and pursue genetic testing. However, it is the ability of the factitious-disorder patient to convince the practitioner to depart from standard clinical practices that is a root cause of the morbidity and mortality risks associated with the disorder. Factors that might raise suspicion in such gynecological cases, for instance, are the patient’s not knowing about the cancer treatments received by close relatives, claiming primary cancers in both breasts, showing an unusual disease pattern, offering other medical complaints determined to be false, giving a history that cannot be corroborated through family reports or outside records, and overeagerly pursuing surgery. This case highlights the fact that the consequences of factitious disorder can be irreversible and iatrogenic. Although it may seem counterintuitive, in at least one case, physicians were sued because they administered treatment based upon a fallacious his-
tory. (The case was settled for a dollar amount in six figures.)2 Marc D. Feldman, M.D. Dept. of Psychiatry and Behavioral Medicine James C. Hamilton, Ph.D. Dept. of Psychology Univ. of Alabama, Tuscaloosa, AL
References
1. Feldman MD: Prophylactic bilateral radical mastectomy resulting from factitious disorder. Psychosomatics 2001; 42:519–521 2. Lipsitt DR: The factitious patient who sues (letter). Am J Psychiatry 1986; 143:1482
Serotonin Syndrome Associated With Citalopram and Meperidine TO THE EDITOR: Serotonin syndrome (SS) is serious and poses a potentially life-threatening risk, resulting when two or more serotonin reuptake-inhibiting medications are used together. Although some agents are quickly recognized as serotonergic, others are less well-known. We describe a unique case of SS in a hospitalized patient when meperidine was added to a medication regimen that included citalopram. Case Report “Ms. C,” a 44-year-old woman who had had surgical resection of rectal cancer, was diagnosed with depression shortly after her cancer diagnosis. She was started on citalopram 20 mg by mouth (po) daily. Nine months later, she was admitted to surgery for debridement of the rectal wound. She was on the surgery ward when her depression significantly worsened. Psychiatry helped with the patient’s symptoms as per the requesting ward team; we provided psychotherapy and increased citalopram to 40 mg po daily. Her depression steadily improved 361
Letters over several weeks. Thus, it was a surprise when Ms. C. was found to be “behaving very oddly” one night. She was experiencing acute agitation, disorientation, paranoia, perceptual disturbances, and nausea. Simultaneously, she spiked a temperature of 39.1⬚C. Her systolic blood pressure was 161 mmHg, and her diastolic blood pressure was 86 mmHg. Respirations were 22 per minute, and heart rate was 112 beats per minute. The Psychiatry Dept. was not contacted that night because these symptoms were believed a typical part of her “psychiatric condition.” Her medical work-up included computed tomography (CT), ECG, and chest X-ray, all of which were normal. Physical examination uncovered a localized wound infection, and blood cultures revealed no growth after 5 days. Laboratory results included an elevated total white bloodcell count of 14,500 l/L, platelet count of 531,000 l/L, and hemoglobin and hematocrit of 13 g/dl and 39%, respectively. A complete metabolic panel was within normal limits. Review of her as-needed (prn) medications revealed hydromorphone 50 mg intravenously (IV) every 6 hours (q 6 hr.) for pain, hydrocodone bitartrate-acetaminophen 5 mg/500 mg po q 6 hr. for pain, and promethazine 12.5 mg IV q 6 hr. for nausea. For breakthrough pain, patient-controlled anesthesia with meperidine had been added before onset of the symptoms. The total parenteral dose of meperidine, over 8 hours, was 230 mg. Ms. C’s symptoms began within 10 hours of starting meperidine, and then stopped 12 hours after discontinuation. Once meperidine was stopped, no episodes occurred during the next 3 months. Gatifloxacin, for treatment of the wound infection, had been initiated 5 days before symptom onset and then continued for 5 more days, for a total 362
http://psy.psychiatryonline.org
10-day course. Other medications included zolpidem tartrate 10 mg before bedtime (hs), lansoprazole 30 mg twice daily (bid), subcutaneous enoxaparin sodium 30 mg twice daily (bid), and a fentanyl patch 50 mcg/hour every 72 hours. Discussion SS is a serious, potentially life-threatening condition resulting from hyperstimulation of 5-hydroxytriptamine (5HT) receptors. The diagnosis is based on Sternbach’s criteria.1 Three of the following must be satisfied: mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, or fever. Symptoms coincide with initiation of, addition of, or increase in dosage of a serotomimetic agent. Other etiologies are excluded. Finally, a neuroleptic agent should not have been initiated or increased in dosage before onset of signs and symptoms.1,2 Ms. C was on citalopram for 9 months, with a dose increase 5 weeks before symptom onset. Her symptoms began within 24 hours of meperidine administration, and she was confused, agitated, febrile, hypertensive, tachycardic, and tachypneic. These symptoms resolved 12 hours after meperidine was discontinued. A careful MEDLINE search, using keywords, “serotonin syndrome,” “citalopram,” “meperidine,” and “SSRI” found no reported cases of SS with citalopram and meperidine together. The literature did reveal reports with citalopram and other serotonergic agents,3 and serotonergic agents and meperidine,4 as well as meperidine and monoamine oxidase inhibitors.5 There was one case with fluoxetine and meperidine.6 Evidence suggests that fentanyl may possibly block serotonin reuptake.4,7 The patient’s other medications
have negligible affinity for the 5-HT receptor.7 Potential dangers, including SS, may occur when medically ill patients are prescribed serotonergic agents. Sometimes, medications like meperidine are not immediately identified as serotonergic, and are added to a patient’s regimen. There currently is no contraindication to their coadministration, and prescribers may not receive warnings about their simultaneous use. Because of their overall safety compared with older antidepressants, clinicians may underestimate the potential for SSRIs and newer serotonergic medications to cause serious morbidity. Serotonergic agents should only be used with meperidine-type analgesics when the benefits to the patient’s health outweigh the potential consequences. Evan M. Altman, D.O., Chief Resident Gail H. Manos, M.D., Training Director Dept. of Psychiatry, Naval Medical Center, Portsmouth, VA References
1. Sternbach H: The serotonin syndrome. Am J Psychiatry 1991; 148:705–713 2. Boyer EW, Shannon M: The serotonin syndrome. N Engl J Med 2005; 352:1112–1120 3. Mahlberg R, Kunz D, Sasse J, et al: Serotonin syndrome with tramadol and citalopram. Am J Psychiatry 2004; 161:1129 4. Giese SY: Serotonin syndrome: potential consequences of Meridia combined with Demerol or fentanyl. Plast Reconstr Surg 2001; 107:293–294 5. Latta KS, Ginsberg B, Barkin RL: Meperidine: a critical review. Am J Therapeut 2002; 9:53–68 6. Tissot TA: Probable meperidine-induced serotonin syndrome in a patient with a history of fluoxetine use. Anesthesiology. 2003; 98:1511–1512 7. Baldessarini RJ: Drugs and the treatment of psychiatric disorders: depression and anxiety disorders, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 10th Ed. Edited by Hardman JG,
Psychosomatics 48:4, July-August 2007
Letters Limbird LE. New York, McGraw-Hill, 2001, pp 456–460
Antibiomania and Ciprofloxacin-Induced Mania TO THE EDITOR: There have been increasing reports of mania associated with administration of antibiotics in patients without a previous history of bipolar disorder. The report by Bhalerao et al. (2006)1 of mania induced by ciprofloxacin is interesting, although it does not appear to be the first report of this association. Although Bhalerao et al.1 cite the article by Abouesh et al. on antibiomania,2 they do not report that the cited article describes 23 cases of ciprofloxacin-induced mania, 12 from the 1997 WHO database, and 11 from the FDA database. It appears that clarithromycin, fluoroquinolones (including ciprofloxacin and ofloxacin), and isoniazid, among antibiotic drugs, are most frequently associated with development of mania.2,3 These three antibiotics are attributed to 90% of all published cases of mania secondary to antibiotics— 66% of the cases in the WHO database and 85% of cases in the FDA database, respectively.2 It is thought that the mechanism of antibiotic-induced mania is related to GABA-antagonism, and there is some evidence that ciprofloxacin is a GABA-antagonist. Interestingly, four WHO-database patients (33%) and five of the FDAdatabase patients (45%) were also prescribed agents that are either known or suspected of causing manic symptoms.
Psychosomatics 48:4, July-August 2007
Similarly, three patients in the WHO database (25%) and two in the FDA database (18%) were concurrently taking mood-stabilizing agents (lithium, carbamazepine, and/or valproate). Applying the Naranjo adverse drug reactions (ADR) probability scale criteria4 to the case described by Bhalerao et al.,1 the manic episode appears, at most, only a “possible” (less likely than a “probable” or “definite”) reaction to ciprofloxacin. The patient described by Bhalerao et al.1 presented at admission with symptoms of anorexia and fatigue, and was possibly depressed. Ulcerative colitis,5 primary biliary cholangitis (and, specifically, fatigue in that condition), and treatment with sulfasalazine6 have all been associated with depression. It is not entirely clear whether sulfasalazine prescribed (potentially long-term) this patient was stopped along with other drugs on discharge. As Helzer et al.5 lament, despite the fact that more than one-quarter of ulcerative colitis patients have some diagnosable psychiatric illness, the occurrence of psychiatric disorder is rarely documented in their medical charts. Whether there were depressive symptoms before admission or not, this could well be a first episode of mania in a young man responding to antipsychotic treatment. It would be helpful to know whether he had a family history of bipolar disorder or any other psychiatric disorder. Interestingly, metronidazole coprescription, also relevant in this case,1 was also prescribed in several cases
(N⳱10) of antibiotic-induced mania.2 Although metronidazole was stopped before discharge, its contribution to the development of mania needs to be considered. The onset of agitation/violence occurred after discharge, but the onset of a milder, hypomanic episode might have been missed, possibly even contributing to the apparent “quick clinical improvement” on a medical ward. If that is true, any of the other drugs could easily have also been responsible for the manic symptoms. Niraj Ahuja, M.B.B.S., M.D., M.R.C.Psych. Adrian J. Lloyd, M.B.B.S., M.D., M.R.C.Psych. Wallsend Community Mental Health Team Sir G.B. Hunter Memorial Hospital, The Green, Wallsend, NE28 7PD, UK References
1. Bhalerao S, Talsky A, Hansen K, et al: Ciprofloxacin-induced manic episode. Psychosomatics 2006; 47:539–540 2. Abouesh A, Stone C, Hobbs WR: Antimicrobial-induced mania (antibiomania): a review of spontaneous reports. J Clin Psychopharmacol 2002; 22:71–81 3. (Anonymous): Mania induced by antimicrobial agents, mainly, isoniazid, clarithromycin, and fluoroquinolones. Prescrire Intl 2003; 12:183 4. Naranjo CA, Busto U, Sellers EM, et al: Method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30:239–245 5. Helzer JE, Stillings WA, Chammas S, et al: A controlled study of the association between ulcerative colitis and psychiatric diagnoses. Dig Dis Sci 1982; 27:513–518 6. Rebrov VG, Lukomskii MI: A case of depression in the treatment of nonspecific ulcerative colitis with sulfasalazine. Klin Med (Moscow) 1989; 67:106
363