1
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Wallace B, Edwardes D, Subbe C, Murtaza M. Interaction between methadone and clarithromycin as the suspected cause of an opioid toxidrome. Drug Ther Bull 2023; 61:12-15. [PMID: 36008097 DOI: 10.1136/dtb.2022.240647rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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2
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Snipes GM, Hafeez A, Marek G, Winchester DE. Sinus bradycardia with haemodynamic compromise following lithium intoxication. Drug Ther Bull 2022; 60:188-191. [PMID: 36008098 DOI: 10.1136/dtb.2022.242946rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Garrett Michael Snipes
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Adam Hafeez
- Department of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - George Marek
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - David E Winchester
- Department of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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3
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Abstract
Central pontine myelinolysis (CPM) develops due to acute hypernatremia from a normal baseline serum sodium in the setting of electrolyte abnormalities induced by topiramate use. Topiramate is a commonly used medication with several indications including migraines, myoclonic jerks and seizures. It has been reported to cause renal tubular acidosis and severe electrolyte abnormalities, which in turn predispose patients to neuropathology via renal concentration defects and osmotic shifts. Our patient is a 55-year-old woman with a history of multiple sclerosis and myoclonus on topiramate for several years who presented with weakness and was found to be profoundly hypokalemic. She went on to develop changes in mental status, motor deficits and evidence of CPM on MRI during her hospitalisation. Surprisingly, the patient never had hyponatremia; however, she had an acute rise in serum sodium from a normal baseline after fluid resuscitation with normal saline for hypotension during her admission.
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Affiliation(s)
- Luba Muaddi
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA .,Division of Nephrology and Hypertension, Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Omar Osman
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Division of Nephrology and Hypertension, Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Barbara Clark
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA .,Division of Nephrology and Hypertension, Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
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4
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Abstract
Lithium is a medication with a variety of medical usage for various diseases including bipolar mood disorder. As the therapeutic window of lithium is narrow, its usage is commonly associated with toxicity. Lithium toxicity affects multiple systems especially the central nervous system, leading to neuropsychiatric complications. Haemodialysis is an effective method for lithium removal especially in severe lithium toxicity such as neurotoxicity with electroencephalogram changes. We describe a case of lithium neurotoxicity with electroencephalographic abnormalities which was reversed following haemodialysis.
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Affiliation(s)
- Hui Jan Tan
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Kuan Yee Lim
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Rathika Rajah
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Chen Fei Ng
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
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5
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Abstract
Delirious mania (the coexistence of delirium and mania) is described in the literature but not recognised in standard nosologies. We report a woman in her late 30s, with no psychiatric history, who presented with concurrent symptoms of mania and delirium. She was diagnosed with COVID-19 pneumonia (positive reverse transcription-PCR test). There was no history of substance misuse or concurrent medical illness. CT head scan was normal as were blood investigations, other than elevated inflammatory markers. She received standard treatment for COVID-19 pneumonia and lorazepam and quetiapine to treat her neuropsychiatric symptoms. She made a full recovery after 9 days. She was apyrexial with normal oxygen saturation throughout her illness. The case shows that severe neuropsychiatric symptoms can complicate otherwise mild COVID-19 pneumonia with neuroinflammation being a possible mechanism. A diagnosis of delirious mania appears to better capture the complexity of the presentation than a diagnosis of mania or delirium alone.
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Affiliation(s)
| | - Majid Alabdulla
- Consultation Liaison Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Javed Latoo
- Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Yousaf Iqbal
- Psychiatry, Hamad Medical Corporation, Doha, Qatar
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6
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Gee SH, Wratten C, Cairns R, Santhouse A, Taylor D. Intravenous ketamine for rapid treatment of major depressive disorder in the general medical hospital. BMJ Case Rep 2021; 14:e239587. [PMID: 34645623 PMCID: PMC8515454 DOI: 10.1136/bcr-2020-239587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/04/2022] Open
Abstract
Major depressive disorder (MDD) is common in general medical settings, and can usually be treated with conventional oral antidepressants. For some patients, however, oral treatment is refused or not possible, and the untreated symptoms can have a significant impact on the treatment of the acute medical problem. Use of intravenous ketamine has been widely reported in mental health settings for the treatment of MDD. We describe use of intravenous ketamine in a general medical hospital for the treatment of MDD in an 83-year-old male patient who refused food, fluid and medical investigations following a stroke.
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Affiliation(s)
- Siobhan Helen Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Camille Wratten
- Department of Psychological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Ruth Cairns
- Department of Psychological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Alastair Santhouse
- Department of Psychological Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College London, London, UK
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7
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Abstract
Lithium is an effective mood stabiliser used to treat bipolar affective disorder (BPAD); however, it can also adversely affect the kidneys, causing acute toxic effects, nephrogenic diabetes insipidus, chronic renal dysfunction and end-stage kidney disease (ESKD) in a minority of patients. We describe the case of a man with a 34-year history of BPAD type-1 and a 2-year history of ESKD secondary to lithium-induced nephropathy who experienced a manic relapse. He previously responded well to lithium but, following a deterioration in kidney function, was switched to olanzapine and sodium valproate. This precipitated a period of instability, which culminated in a treatment-resistant manic episode requiring hospital admission. After a multidisciplinary team discussion, lithium therapy was restarted and provided remission. This was achieved safely through a reduced dosing schedule of three times a week post dialysis, slow dose titration and blood level monitoring prior to each dialysis session.
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Affiliation(s)
- Sam Topp
- Hounslow Crisis Assessment & Treatment Team, West London Mental Health NHS Trust, Isleworth, UK
| | - Emma Salisbury
- Renal and Transplant, Imperial College Healthcare NHS Trust, London, UK
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8
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Abstract
Coexistence of idiopathic Parkinson's disease (iPD) and schizophrenia can pose great diagnostic and therapeutic challenges because of their pathophysiology. Our case highlights such challenges in management. We present a case of 73-year-old man who had parkinsonism for last several years and was also diagnosed with schizophrenia. Due to lack of collateral information about the onset of symptoms and clinical course, it was difficult to distinguish iPD from neuroleptic-induced parkinsonism. Even though, certain clinical findings may help to differentiate between the two conditions, single positron emission computerized tomography/DatScan was used to confirm the diagnosis of iPD. Treatment of coexisting iPD and schizophrenia can be challenging, and a delicate pharmacologic balance must be maintained to ensure adequate symptomatic control. Current evidence suggests that clozapine is a better choice for managing psychosis in these patients due to its unique receptor profile and better safety data.
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Affiliation(s)
- Amna Ramzan
- Department of Neurology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA
| | - Ruchi Aggarwal
- Department of Psychiatry, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA
| | - Fariha Jamal
- Department of Neurology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA
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9
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Abstract
We present a case of benzodiazepine withdrawal delirium in a middle-aged man undergoing spinal surgery. Benzodiazepines were stopped prior to surgery and on postoperative day 4, the patient exhibited significant paranoia, hyperarousal and ideas of reference. Patient's symptoms resolved after reintroduction of his benzodiazepines. It is important to include benzodiazepine withdrawal in the differential diagnosis for acute delirium even in those patients taking low or moderate doses. Benzodiazepine withdrawal delirium typically responds rapidly to restarting benzodiazepines. In patients with known discontinuation issues, early consultation with consult-liaison psychiatry and preoperative planning for early medication re-initiation is paramount.
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Affiliation(s)
- Eric William Lutz
- Behavioral Health, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Christopher Hines
- Behavioral Health, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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10
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Wallace B, Edwardes D, Subbe C, Murtaza M. Interaction between methadone and clarithromycin as the suspected cause of an opioid toxidrome. BMJ Case Rep 2021; 14:14/5/e240647. [PMID: 34035018 PMCID: PMC8154935 DOI: 10.1136/bcr-2020-240647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A 40-year-old patient was admitted through the acute medical take with pleuritic chest pain and rigours. He had a medical history of opiate dependence and was receiving 60 mg of methadone once daily. He was diagnosed with a community-acquired pneumonia and treated with amoxicillin and clarithromycin. After administration of only two concomitant doses of methadone and oral clarithromycin, he developed an opioid toxidrome with type-2 respiratory failure, a decreased level of consciousness and pinpoint pupils. The patient was treated with naloxone and his symptoms improved. Retrospectively, it was suspected that an interaction between clarithromycin and methadone might have contributed to the toxidrome. Respiratory failure has not been previously prescribed for this combination of medication and is of high importance for physicians and pharmacists around the world.
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11
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Abstract
Lithium is a well-established treatment for mood disorders and considered first-line pharmacological therapy for bipolar disorder as per the American Psychiatric Association guidelines. However, lithium is associated with significant toxicity. Cardiotoxicity including sinus node dysfunction is a rare but clinically significant presentation of lithium intoxication. This case report describes an adult male presenting with unstable sinus bradycardia in the setting of acute kidney injury and elevated serum lithium levels. The patient required temporary management with inotropic support and transcutaneous pacing. The patient's heart rate and hypotension improved in parallel with resolution of his acute kidney injury and elevated serum lithium level after treatment with intravenous fluids. Given the prevalence of bradycardia in both the outpatient and inpatient settings, a high index of suspicion is necessary for the prevention and identification of this clinical entity to guide appropriate management.
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Affiliation(s)
- Garrett Michael Snipes
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Adam Hafeez
- Department of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - George Marek
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - David E Winchester
- Department of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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12
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Abstract
This is a case report of a middle-aged man with no psychiatric history who presented with severe anxiety and psychotic symptoms from COVID-19. Following his discharge from intensive care unit, he was unable to sleep, was increasingly agitated and was observed hitting his head off the walls, causing haematomas. He remained highly anxious and developed paranoid delusions and auditory and tactile hallucinations, needing admission to a psychiatric ward. Treatment with antipsychotic medication gradually improved his symptoms in a few weeks. This case report highlights the new onset of psychosis due to COVID-19 infection. It demonstrates the importance of early identification and treatment of neuropsychiatric complications within an acute hospital setting. Furthermore, there is a need for research in this area to help in the prevention and treatment of such psychiatric complications due to COVID-19.
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Affiliation(s)
- Nana Kozato
- South West London and St George's Mental Health NHS Trust, Roehampton, UK
| | - Monisha Mishra
- South West London and St George's Mental Health NHS Trust, London, UK
| | - Mudasir Firdosi
- South West London and St George's Mental Health NHS Trust, London, UK .,St George's University of London, London, UK
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13
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Abeysundera H, Craig B, Pullich Z. Promethazine-induced delirium with perceptual abnormalities: are we thinking broadly when assessing patients? BMJ Case Rep 2021; 14:e241784. [PMID: 33858904 PMCID: PMC8054040 DOI: 10.1136/bcr-2021-241784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 11/04/2022] Open
Abstract
There is limited information about promethazine-induced delirium with psychotic symptoms. The aim is to highlight the importance of taking a detailed history including medication use/abuse of both prescribed, illicit and over-the-counter preparations. This paper describes a patient who presented with delirium in the context of overuse of promethazine (Phenergan) which was initially missed. The patient was treated successfully, following the diagnosis of promethazine-induced delirium. Clinicians should be aware of assessing patients presenting with delirium to explore the possibility of over-the-counter medication misuse.
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Affiliation(s)
- Hesitha Abeysundera
- Psychiatry, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Bailey Craig
- Psychiatry, Bond University, Robina, Queensland, Australia
| | - Zelle Pullich
- Psychiatry, Gold Coast University Hospital, Southport, Queensland, Australia
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14
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Abstract
A 57-year-old woman presented with a 1-year history of major depressive disorder. She was started on venlafaxine XR 75 mg orally daily and a few days later developed severe dysosmia to foods she used to enjoy. She never had previous problems with smell or taste. At her 1-month follow-up, her depressive symptoms had improved, but she reported persistent dysosmia and was found to have associated weight loss due to decreased oral intake. She was advised to switch medications, but due to financial constraints she continued taking the same dose. At follow-up 48 days later, she reported complete resolution of her dysosmia and was eating normally again, but she had persistence of some depressive symptoms so her dose was gradually increased to venlafaxine XR 225 mg orally daily until her depressive symptoms and postmenopausal hot flashes were well controlled. There were no changes with continued use over the following 8 years.
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Affiliation(s)
| | - John Malaty
- Community Health and Family Medicine, University of Florida Health, Gainesville, Florida, USA
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15
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Takao N, Murai T, Fujiwara H. Treatment-resistant schizophrenia characterised by dopamine supersensitivity psychosis and efficacy of asenapine. BMJ Case Rep 2021; 14:e242495. [PMID: 33849886 PMCID: PMC8051386 DOI: 10.1136/bcr-2021-242495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/21/2022] Open
Abstract
Dopamine supersensitivity psychosis (DSP) frequently arises with long-term antipsychotic treatment and accounts for a significant proportion of treatment-resistant schizophrenia. The mechanism underlying DSP is thought to be a compensatory increase in dopamine receptor density in the striatum caused by long-term antipsychotic treatment. Previous animal studies have reported that antipsychotics increase serotonin 5-HT2A receptor density in the striatum and that 5-HT2A receptor blockers suppress dopamine-sensitive psychomotor activity, which may be linked to the pathophysiology of DSP. In this paper, we describe a patient who was hospitalised with treatment-resistant schizophrenia. Following treatment with high-dose antipsychotic polypharmacy for 10 weeks, the patient experienced worsening of psychotic and extrapyramidal symptoms. The patient was then started on second-generation antipsychotic asenapine while other antipsychotics were tapered off, resulting in improvement of these symptoms. Retrospectively, we presumed that the high-dose antipsychotic polypharmacy caused DSP, which was effectively treated by the potent 5-HT2A receptor antagonism of asenapine.
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Affiliation(s)
- Nagara Takao
- Psychiatry, Kyoto University Hospital, Kyoto, Japan
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16
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Abstract
Many patients with chronic fatigue syndrome (CFS) fail to derive benefit from evidence-based treatments such as cognitive-behavioural therapy (CBT) and graded exercise therapy leading to permanent disability. To discover whether a repeat prescription of modafinil might potentiate the benefits of CBT leading to social recovery as defined by 2 or more point improvement in energy and muscular pain/concentration and return to work or full-time training. Three patients with treatment-resistant CFS (mean duration 17.66 years) treated with modafinil and CBT in a Liaison Psychiatry clinic were retrospectively reviewed. Progress was reviewed at baseline, 4-6 months and 10-24 months. Patients rated their fatigue, pain and concentration using 10-point Likert scales. 2/3 achieved clinically meaningful improvements in energy and pain/concentration and 3/3 achieved social recovery. Modafinil, when prescribed over the medium term, would appear to be a potentially useful potentiating agent when added to CBT.
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Affiliation(s)
- Himanshu Garg
- Adult Services, Bradford District Care NHS Foundation Trust, Bradford, UK
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17
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Porter KMF, Hargreaves IP, De Souza S, Goddard R. Treatment with the direct oral anticoagulants (DOACs) apixaban and rivaroxaban associated with significant worsening of behavioural and psychological symptoms of dementia (BPSD). BMJ Case Rep 2021; 14:e240059. [PMID: 33685912 PMCID: PMC7942237 DOI: 10.1136/bcr-2020-240059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 11/29/2022] Open
Abstract
We report the cases of two patients who developed worsening behavioural and psychological symptoms of dementia (BPSD), coinciding with starting the factor Xa inhibitor direct oral anticoagulant medications apixaban and rivaroxaban, respectively. Both patients required detaining under the Mental Health Act. Their symptoms improved significantly, within 2 weeks, on switching to alternative anticoagulant therapies and they were both discharged from the acute psychiatric ward. Front-line staff should partake in postmarketing surveillance of medications, completing the Medicines and Healthcare products Regulatory Agency yellow cards for example (UK). There is increasing evidence for an aetiological role of cerebral mitochondrial dysfunction in neuropsychiatric disorders. Development of a rating scale of drugs that are potentially less toxic to cerebral mitochondria could inform national prescribing guidelines and enable safer treatments to be offered to older people, reducing the likely hood of them experiencing apparent BPSD.
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Affiliation(s)
| | - Iain Parry Hargreaves
- Department of Molecular Neuroscience, UCL Queen Square Institute of Neurology, National Hospital, London, UK
| | - Stephen De Souza
- Older Peoples Psychiatric Inpatient Unit, Somerset NHS Foundation Trust, Taunton, Somerset, UK
| | - Rebecca Goddard
- Complex Treatment and Intervention Team, Avon and Wiltshire Mental Health Partnership NHS Trust, Midsomer Norton, Somerset, UK
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18
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Abstract
Deep vein thrombosis has been recognised as a complication of antipsychotic treatment and is reported to be more common with atypical antipsychotics. Risperidone is a second-generation atypical antipsychotic and there have been case reports of risperidone-associated deep vein thrombosis, most of them reporting the complication from 2 weeks to a few months of initiation of therapy. Here, we are reporting a case of deep vein thrombosis in a male patient in his early forties with paranoid schizophrenia, which presented on the fourth day of starting risperidone therapy. This case is being reported to highlight the fact that deep vein thrombosis can occur as early as fourth day of initiation of risperidone therapy, that too at a low dose (2 mg/day). The case also emphasises the importance of monitoring these patients for this rare but potentially serious adverse effect from the first day itself after initiation of a new antipsychotic.
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Affiliation(s)
| | - Mithila George
- Department of Psychiatry, Government Medical College, Ernakulam, Cochin, Kerala, India
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19
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Abstract
We describe a case of a young man, taking no other routine medications, presenting with erythema multiforme and cetirizine-induced psychosis with re-challenge evidence. On retrospective elicitation of history, it was found that he had been involved in a motor vehicle collision 4 months prior and was a daily cannabis user; there were no objective abnormalities by MRI and neurological evaluations. Although rare, cetirizine-induced psychosis is an important adverse drug reaction that warrants the attention of healthcare practitioners.
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Affiliation(s)
- David Croitoru
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Lindsey MacGillivray
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University Health Network, Toronto, Ontario, Canada
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20
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Olds J, Yousif M, Abidakun O, Cannon A. Case of recurrent cerebral haemorrhage in an older adult man who uses dimethylsulfoxide (DMSO) for self-management of low mood and pain. BMJ Case Rep 2021; 14:14/2/e240371. [PMID: 33541956 PMCID: PMC7868225 DOI: 10.1136/bcr-2020-240371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We present the case of a man in his 70s who had suffered two separate frontal lobe haemorrhages in the context of using dimethylsulfoxide (DMSO) to manage his low mood. The known pathophysiology of DMSO renders it a likely causative agent of the recurrent intracerebral haemorrhages. This case highlights the need for clinicians to robustly enquire about a patient's use of over-the-counter medications, of non-prescribed supplements and other substances, as part of the history. In addition, the case highlights the potential for highly debilitating adverse effects from using DMSO.
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Affiliation(s)
- Jonathan Olds
- Later Life Liaison Psychiatry, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mohamed Yousif
- Department of Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Oladotun Abidakun
- Department of Stroke Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Abigail Cannon
- Department of Geriatric Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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21
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Abstract
Upside-down reversal of vision (UDRV) is a rare form of metamorphopsia, or visual illusions that can distort the size, shape or inclination of objects. This phenomenon is paroxysmal and transient in nature, with patients reporting a sudden inversion of vision in the coronal plane, which typically remains for seconds or minutes, though occasionally persists for hours or days, before returning to normal. Distorted egocentric orientation (ie, the patient perceives the body to be tilted away from the vertical plane) is even more rare as a co-occurring phenomenon. To the best of our knowledge, this is the first reported case of a veteran who presented with UDRV and distorted egocentric orientation during hospitalisation on an inpatient physical medicine and rehabilitation setting following an elective hip surgery. This case serves not only to document the presence of rare visual illusions, but also illustrates the importance and value of an interdisciplinary team approach.
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Affiliation(s)
- Michelle Zeller
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Wilhelmina Stamps
- Graduate School of Education and Psychology, Pepperdine University, Los Angeles, California, USA
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22
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Abstract
A 30-year-old man with no significant previous or family psychiatric history became severely anxious about his health after a positive COVID-19 test. Physical symptoms of COVID-19 were mild, with no evidence of hypoxia or pneumonia, throughout his illness. He was admitted to a quarantine facility. He remained highly anxious, and 1 week later, he developed paranoid delusions and auditory hallucinations (his first psychotic episode). He was treated with lorazepam 1 mg four times a day, mirtazapine 30 mg nocte and risperidone 1 mg two times a day. His psychotic symptoms lasted 1 week. He stopped psychiatric medication after 4 weeks and had remained well when reviewed 3 months later. A Diagnostic and Statistical Manual of Mental Disorders fifth edition diagnosis of brief psychotic disorder with marked stressor (brief reactive psychosis) was made. Anxiety about his health and social isolation appeared the main aetiological factors but an inflammatory component cannot be excluded. The case highlights that first episode psychosis can be associated with mild COVID-19.
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Affiliation(s)
- Peter M Haddad
- Psychiatry, Hamad Medical Corporation, Doha, Qatar
- Clinical Department, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Majid Al Abdulla
- Clinical Department, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Javed Latoo
- Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Yousaf Iqbal
- Clinical Department, College of Medicine, QU Health, Qatar University, Doha, Qatar
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23
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Verhoeven WMA, Egger JIM, Janssen PKC, van Haeringen A. Adult male patient with severe intellectual disability caused by a homozygous mutation in the HNMT gene. BMJ Case Rep 2020; 13:13/12/e235972. [PMID: 33310825 PMCID: PMC7735107 DOI: 10.1136/bcr-2020-235972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Histamine is involved in various physiological functions like sleep–wake cycle and stress regulation. The histamine N-methyltransferase (HNMT) enzyme is the only pathway for termination of histamine neurotransmission in the central nervous system. Experiments with HNMT knockout mice generated aggressive behaviours and dysregulation of sleep–wake cycles. Recently, seven members of two unrelated consanguineous families have been reported in whom two different missense HNMT mutations were identified. All showed severe intellectual disability, delayed speech development and mild regression from the age of 5 years without, however, any dysmorphisms or congenital abnormality. A diagnosis of mental retardation, autosomal recessive 51 was made. Here, we describe a severely mentally retarded adolescent male born from second cousins with a homozygous mutation in HNMT. His phenotypic profile comprised aggression, delayed speech, autism, sleep disturbances and gastro-intestinal problems. At early age, regression occurred. Treatment with hydroxyzine combined with a histamine-restricted diet resulted in significant general improvement.
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Affiliation(s)
- Willem M A Verhoeven
- Centre of Excellence for Neuropsychiatry, Vincent Van Gogh Institute, Venray, The Netherlands .,Department of Psychiatry, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jos I M Egger
- Centre of Excellence for Neuropsychiatry, Vincent Van Gogh Institute, Venray, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Paddy K C Janssen
- Department of Hospital Pharmacy, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Arie van Haeringen
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
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24
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Abstract
Mephentermine is a vasopressor drug closely related to amphetamine and methamphetamine. Cases of abuse and dependence to mephentermine have dotted medical literature for a long time. Till date, 11 cases of dependence to mephentermine have been published. In this report, a case of mephentermine dependence is being discussed. The patient was a young adult male who was dependent to mephentermine for nearly 3 years. He was an athlete and was introduced to mephentermine by his peer for enhancing performance. He did not develop any major physical or psychiatric issue due to the drug. He was managed on out patient basis. Though cases of mephentermine dependence are few and far in medical literature, reports from other sources indicate that the problem could be more common and could be on rise. High index of suspicion and holistic care is likely to help patients and treating clinicians.
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Affiliation(s)
- Aditya Somani
- Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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25
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Sharma N, Bhat S, Ravi D, Ochieng P. Republished: Severe hypothermia, bradycardia and cardiac arrest in association with risperidone. Drug Ther Bull 2020; 59:13-15. [PMID: 33093075 DOI: 10.1136/dtb.2020.234999rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Nishant Sharma
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Sangeeta Bhat
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Divya Ravi
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Pius Ochieng
- Pulmonary and Critical Care Medicine, Geisinger Community Medical Center, Scranton, Pennsylvania, USA
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26
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Abstract
Anxiety disorders in young people are frequently comorbid with other mental disorders and respond unsatisfactorily to first-line treatment in many cases. Here, we report the case of a 20-year-old man with severe social anxiety disorder, major depressive disorder, insomnia and attenuated psychotic symptoms despite ongoing treatment with cognitive behavioural therapy and mirtazapine who was treated with adjunctive cannabidiol (CBD) in doses between 200 and 800 mg/day for 6 months. During treatment with CBD, he experienced subjective benefits to his anxiety, depression and positive symptoms during treatment that were confirmed by clinicians and by standardised research instruments. Findings from this case study add to existing evidence in support of the safety of CBD and suggest that it may be useful for young people with treatment refractory anxiety and for attenuated psychotic symptoms.
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Affiliation(s)
- Maximus Berger
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia .,Orygen, Melbourne, Victoria, Australia
| | - Emily Li
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Orygen, Melbourne, Victoria, Australia
| | - Günter Paul Amminger
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Orygen, Melbourne, Victoria, Australia
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27
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Abstract
Antipsychotic medications, including risperidone, are widely used in the treatment of psychiatric disorders, including schizophrenia. While hyperthermia is an establish adverse effect of these medications, less is known about the rare occurrence of hypothermia. We present two patients who developed hypothermia, bradycardia and cardiac arrest in association with risperidone. We briefly review previously similarly reported cases.
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Affiliation(s)
- Nishant Sharma
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Sangeeta Bhat
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Divya Ravi
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Pius Ochieng
- Pulmonary and Critical Care Medicine, Geisinger Community Medical Center, Scranton, Pennsylvania, USA
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28
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Caulfield MDG, Brar R, Sutherland C, Nolan S. Transitioning a patient from injectable opioid agonist therapy to sublingual buprenorphine/naloxone for the treatment of opioid use disorder using a microdosing approach. BMJ Case Rep 2020; 13:13/3/e233715. [PMID: 32213504 DOI: 10.1136/bcr-2019-233715] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In the wake of North America's opioid crisis, access to evidence-based treatment for opioid use disorder (OUD) is of critical importance. While buprenorphine/naloxone and methadone are currently indicated as first-line medications for the treatment of OUD, there are a proportion of individuals who do not benefit from these therapies. Recent Canadian guidelines suggest the use of alternate therapies, including slow-release oral morphine or injectable opioid agonist therapy (iOAT) for individuals unsuccessful with either methadone or buprenorphine/naloxone. While the guidelines highlight the need to intensify OUD treatment as disease severity increases, equally important is the consideration for deintensification of treatment (eg, from iOAT to an oral opioid agonist treatment (OAT) option) following successful stabilisation. Literature addressing how best to accomplish this, however, is currently lacking. Accordingly, the case presented here describes a patient that successfully transitions from iOAT to oral buprenorphine/naloxone using a novel induction approach termed microdosing.
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Affiliation(s)
| | - Rupinder Brar
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Christy Sutherland
- Department of Family Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Seonaid Nolan
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada .,BC Centre on Substance Use, Vancouver, British Columbia, Canada
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29
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Virdee G, Bleasdale J, Ikramullah M, Graham-Clarke E. Republished: Sertraline-induced hypersensitivity pneumonitis. Drug Ther Bull 2020; 58:75-79. [PMID: 32188684 DOI: 10.1136/dtb.2019.230724rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Gursharan Virdee
- Pharmacy Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - John Bleasdale
- Critical Care Services, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Mohammed Ikramullah
- Mental Health, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Emma Graham-Clarke
- Critical Care Services, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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30
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Abstract
A 53-year-old woman was admitted to a tertiary intensive care unit (ICU) with acute respiratory distress syndrome secondary to severe community-acquired pneumonia that necessitated maximum supportive care with venovenous extracorporeal membrane oxygenation. Her medical history included bipolar disorder on quetiapine and sertraline, as well as a previous ICU admission, approximately 2 years prior, for non-cirrhotic hyperammonaemic encephalopathy that was complicated by prolonged post discharge anxiety and post-traumatic stress disorder-like symptoms, consistent with post-intensive-care syndrome. Here, we present a case, and explore the outcomes for a patient who had two separate admissions with life-threatening illnesses, but had distinct differences in the psychological outcomes following each illness.
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Affiliation(s)
| | - Andrew Ford
- WA Centre for Health & Ageing, University of Western Australia, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Matthew Anstey
- Intensive Care, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Australia
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31
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Abstract
Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is a granulomatous, non-IgE-mediated hypersensitivity reaction of the alveoli and distal bronchioles presenting as an acute, subacute or chronic condition. It is most commonly associated with exposure to extrinsic allergens (eg, avian dust, mould and tobacco) and medications including antiarrhythmics (eg, amiodarone), cytotoxics (eg, methotrexate) and antiepileptics (eg, carbamazepine). Individuals diagnosed with this condition can present with severe hypoxia and respiratory failure. The fundamental principle of management is to remove the causative allergen. Evidence implicating selective serotonin reuptake inhibitors as a causative agent is limited, and this case report describes a rare clinical presentation of HP associated with sertraline, how it was diagnosed and subsequently treated. It is anticipated that raising awareness of this interaction will assist multidisciplinary teams, managing patients diagnosed with HP, to be more cognisant of sertraline as being an aetiological factor for this condition.
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Affiliation(s)
- Gursharan Virdee
- Pharmacy Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - John Bleasdale
- Critical Care Services, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Mohammed Ikramullah
- Mental Health, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Emma Graham-Clarke
- Critical Care Services, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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32
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Abstract
This case report presents the case of a 29 weeks pregnant woman in her late twenties who was seen at the emergency department of a hospital with a seizure of unknown cause. By anamnesis and hetero-anamnesis the use of illicit gamma-hydroxybutyric acid (GHB) was revealed. Examination showed dilated pupils, sweating, tremor, tachycardia and bradyphrenic thinking. Subsequently, the seizure was indicated as a severe illicit GHB withdrawal symptom. Thereafter, treatment had to be decided on in the absence of evidence-based and practiced-based guidelines and treatment options for this specific patient population. Initially diazepam was started, which was later on substituted by sodium oxybate. Despite the critical professional situation the patient gave birth to a healthy daughter after 37 weeks of pregnancy.
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Affiliation(s)
- J C van Mechelen
- Department of Psychiatry and Medical Psychology, OLVG Location West, Amsterdam, North Holland, the Netherlands
| | - Bag Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Radboud University, Nijmegen, Gelderland, the Netherlands.,Research and development, Novadic-Kentron Addiction Care, Vught, Noord-Brabant, the Netherlands
| | - Acm Vergouwen
- Department of Psychiatry and Medical Psychology, OLVG Location West, Amsterdam, North Holland, the Netherlands
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33
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Abstract
This report presents a case of drug-induced severe tardive akathisia developing after the combination of a selective serotonin reuptake inhibitor and an antipsychotic, in a woman with severe major depression. The trial and combination of multiple medications is common practice in treatment-resistant patients with depression. With the increase in the prevalence of treatment-resistant depression, adverse effects of medication such as tardive akathisia are becoming more common. Tardive akathisia persists even after the withdrawal of the causative agent and is very challenging to treat. The patient did not respond to any standard medications indicated for drug-induced akathisia. As a result, the patient became suicidal and extremely distressed with all treatment options exhausted. Guidelines on the management of drug-induced tardive akathisia are non-existent. This reflects the importance of this case study, which reveals the complete remission of both tardive akathisia and all the patient’s depressive symptoms after electroconvulsive therapy. This report provides evidence of an established treatment intervention used in a new situation.
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Affiliation(s)
- Thanos Emmanuel
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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34
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Burgett RN, Farley TM, Beireis LA. Acute treatment of psychotic symptoms in a newly diagnosed Lewy body dementia patient with an accelerated titration schedule of rivastigmine and de-escalation of antipsychotics. BMJ Case Rep 2019; 12:12/9/e230193. [PMID: 31488443 DOI: 10.1136/bcr-2019-230193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 76-year-old man presented with complaints of increased confusion, visual hallucinations and decline in memory. He was admitted to the hospital and started on quetiapine 50 mg daily for symptom management. Shortly after, he was diagnosed with Lewy body dementia and started on rivastigmine, a cholinesterase inhibitor (ChEI), at 1.5 mg two times per day. The patient's symptoms continued to worsen and antipsychotics increased for aggressive behaviour. After he became physically aggressive, an extensive medication management review was conducted, prompting an alternative treatment strategy. The quetiapine dose was reduced from 150 mg daily to 12.5 mg daily, his rivastigmine was increased to 3 mg two times per day and all other antipsychotics were discontinued. The up-titration of his rivastigmine after 10 days of therapy was well tolerated with no adverse effects. He demonstrated a clear clinical response to optimised ChEI therapy and low dose quetiapine, showing improvements in alertness and functioning.
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Affiliation(s)
- Rebecca Nicole Burgett
- Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, Iowa, USA
| | - Thomas Michael Farley
- Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, Iowa, USA.,Pharmacy, Mercy Hospital Iowa City, Iowa City, Iowa, USA
| | - Lori Ann Beireis
- Internal Medicine, Mercy Hospital Iowa City, Iowa City, Iowa, USA
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35
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Abstract
A 53-year-old woman was admitted with thyroid storm and severe behavioural problems. She had longstanding bipolar affective disorder. She was psychotic and obstructed in-patient medical management for thyroid storm. She required one-to-one psychiatric nursing and was placed under section 3 of the Mental Health Act meaning she could be detained in hospital for psychiatric treatment for up to 6 months. She underwent a total thyroidectomy. Due to her paranoid mental state, she refused treatment and the administration of thyroid hormone replacement was difficult. Postoperatively, intramuscular levothyroxine was used effectively to stabilise her thyroid function. There are no consensus guidelines on the use of parenteral levothyroxine and intramuscular levothyroxine is rarely used. This case uniquely illustrates its utility with bi-weekly blood tests showing a fast and stable response to intramuscular hormone replacement.
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Affiliation(s)
- Kate Laycock
- Diabetes and Endocrinology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Chloe Beale
- Psychiatry, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Catherine Peters
- Intensive Care, Homerton University Hospital NHS Foundation Trust, London, UK
| | - John Anderson
- Diabetes and Endocrinology, Homerton University Hospital NHS Foundation Trust, London, UK
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36
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Abeysundera H, Campbell A, Sarma S. Worsening of movement disorder following treatment with electroconvulsive therapy in a patient with Huntington's disease. BMJ Case Rep 2019; 12:12/8/e230389. [PMID: 31401578 DOI: 10.1136/bcr-2019-230389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This paper describes a patient who presented with treatment-resistant depression with comorbid anxiety symptoms in the context of Huntington's disease (HD) and developed worsening movement disorder symptoms after commencing electroconvulsive therapy (ECT) for depression. The aim of this case report is to provide medical practitioners with a greater awareness of the possibility of worsening movement disorders when using ECT for depression in a patient with HD.
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Affiliation(s)
| | - Allan Campbell
- Department of Psychiatry, Queensland Health, Cairns, Queensland, Australia
| | - Shanthi Sarma
- Department of Psychiatry, Queensland Health, Robina, Queensland, Australia
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37
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Abstract
Clozapine is an atypical antipsychotic used most frequently in the management of treatment-resistant schizophrenia, where severely unwell patients have failed to respond to standard antipsychotic therapy. Clozapine is associated with a number of risks, such as agranulocytosis and long-term cardiometabolic morbidity. Reported less frequently is the risk of severe cardiac complications. The case reported here provides an important example of chronic clozapine toxicity leading to pericarditis. This case also describes a difficult ethical dilemma, where the physical risk to a patient with a diagnosis of schizophrenia must be balanced with the potentially adverse psychiatric risk that would follow, if the patient were to be weaned off this effective antipsychotic therapy. It is frequently reported that clozapine is stopped due to its toxicity. In this case however, the mental health and functional benefit of continuing with clozapine was deemed to outweigh the physical risk of progression of the pericarditis.
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Affiliation(s)
| | - Alvaro Barrera
- Oxford Health NHS Foundation Trust, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK
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38
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Velosa A, Neves A, Barahona-Corrêa JB, Oliveira-Maia AJ. Neuroleptic malignant syndrome: a concealed diagnosis with multitreatment approach. BMJ Case Rep 2019; 12:12/6/e225840. [PMID: 31213433 DOI: 10.1136/bcr-2018-225840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
While neuroleptic malignant syndrome (NMS) is typically characterised by delirium, motor rigidity, fever and dysautonomia, the syndrome is not pathognomonic, and NMS remains a diagnosis of exclusion. Here, we describe the case of a 44-year-old woman, with no relevant psychiatric history, admitted to a nephrology unit due to acute renal failure. After administration of antipsychotics, she presented with mental status alteration, generalised tremor, rigidity and autonomic nervous system dysfunction. Fever and rhabdomyolysis, however, were not prominent, and NMS was not considered initially in the differential diagnosis. The resulting delay in diagnosis, with continued administration of antipsychotics, led to progressive clinical deterioration. Once NMS was considered, however, antipsychotics were withdrawn and the patient was treated with electroconvulsive therapy (ECT), followed by administration of a dopamine receptor agonist, with close to full remission of all symptoms. Importantly, during outpatient follow-up, sustained mild and asymmetric tremor and rigidity was noted, leading to a diagnosis of Parkinson's disease. While this raises questions regarding differential diagnosis between NMS in Parkinson's disease, versus worsening of Parkinson's disease due to antipsychotic treatment, the former is supported by the acute and rapidly progressive onset of exuberant autonomic dysfunction and clouded conscience, after administration of a neuroleptic. Ultimately, a definitive distinction between these two alternatives for diagnosis of the inaugural neurological presentation in this patient is not possible. Nevertheless, we believe this case illustrates that NMS can be easily missed, particularly in atypical cases, delaying appropriate treatment, and that a flexible multimodal treatment approach, involving ECT, should be considered for complex clinical cases. Furthermore, it also underlines the importance of post-NMS follow-up, to investigate underlying neurological or medical disorders, particularly in those patients who do not have a full recovery.
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Affiliation(s)
- Ana Velosa
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - António Neves
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,Department of Psychiatry and Mental Health, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - J Bernardo Barahona-Corrêa
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,Department of Psychiatry and Mental Health, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.,Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Albino J Oliveira-Maia
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.,Department of Psychiatry and Mental Health, NOVA Medical School
- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.,Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
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39
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Marinova Z, Bausch-Becker N, Savaskan E. Anti- N-methyl-d-aspartate receptor encephalitis in an older patient presenting with a rapid onset of delusions and amnesia. BMJ Case Rep 2019; 12:12/4/e228512. [PMID: 30992284 DOI: 10.1136/bcr-2018-228512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
We present the case of a 77-year-old patient with a rapid onset of delusions, amnesia, agitation, insomnia and no previous psychiatric history, who was diagnosed with anti-N-methyl-d-aspartate receptor encephalitis. This case report highlights the importance of including autoimmune encephalitis in the differential diagnosis of older patients presenting with rapid onset psychiatric episodes.
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Affiliation(s)
- Zoya Marinova
- Clinic for Geriatric Psychiatry, Psychiatric University Clinic, Zurich, Switzerland
| | | | - Egemen Savaskan
- Clinic for Geriatric Psychiatry, Psychiatric University Clinic, Zurich, Switzerland
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40
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Abstract
Clozapine is the most effective treatment for patients with refractory schizophrenia. Clozapine is also associated with serious and potentially lethal side effects including drug induced lupus (DIL). There have been four previous published case reports describing clozapine inducing a lupus-like syndrome including one previous case where a clozapine rechallenge was attempted without success. This case report describes a successful clozapine rechallenge in a patient with suspected DIL.
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Affiliation(s)
- Suraj Pathak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, Glenfield Hospital, Leicester, UK
| | - Scott Cherry
- Department of Psychiatry, St Mary's Hospital, Forest Centre, Northamptonshire, UK
| | - Samreen Samad
- Department of Psychiatry, Welland Centre, Northamptonshire, UK
| | - Ambreen Aftab
- Department of Psychiatry, Welland Centre, Northamptonshire, UK
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41
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Affiliation(s)
- Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, 123 Summer Street, Worcester, MA, 01608, United States
| | - Ajay Mishra
- Department of Internal Medicine, Saint Vincent Hospital, 123 Summer Street, Worcester, MA, 01608, United States
| | - Leily Naraghi
- Department of Emergency Medicine, Saint Vincent Hospital, 123 Summer Street, Worcester, MA, 01608, United States
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42
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Patel R, Lima A, Burke C, Hoffman M. Monocytopenia in clozapine-induced agranulocytosis: insights into pathophysiology and treatment. BMJ Case Rep 2019; 12:bcr-2018-226016. [PMID: 30661042 PMCID: PMC6340600 DOI: 10.1136/bcr-2018-226016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2018] [Indexed: 11/04/2022] Open
Abstract
A 26-year-old man with history of schizophrenia was admitted for neutropaenia. He was started on clozapine 3 months prior to admission. As a result he had weekly monitoring of his blood counts and on day of admission was noted to have an absolute neutrophil count (ANC) of 450 cells/μL. He was admitted for clozapine-induced agranulocytosis. Clozapine was held and the patient was started on granulocyte colony-stimulating factor (G-CSF) filgrastim and received two doses without any signs of ANC recovery. On further review, it was noted that the absolute monocyte count (AMC) was also low and tracked with the trend of ANC. We then theorised that the impact of clozapine was on a haematopoietic precursor (colony-forming unit granulocyte-macrophage, CFU-GM) which gives rise to both monocytic and myeloid lineages. Therefore, sargramostim GM-CSF was started. After two doses, the ANC and AMC started trending up and by the third dose, both counts had fully recovered. He was discharged from the hospital and there are no plans to rechallenge with clozapine. Thus, we demonstrate a case of monocytopenia accompanying clozapine-induced agranulocytosis with successful use of GM-CSF. At least in this case, the target of the clozapine injury appears to be the CFU-GM, explaining the rapid and full response to GM-CSF after lack of response to G-CSF.
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Affiliation(s)
- Rajvi Patel
- Monter Cancer Center-Division of Hematology Oncology, Northwell Health, Lake Success, New York, USA
| | - Ateaya Lima
- Department of Psychiatry, Northwell Health, Queens, New York, USA
| | | | - Mark Hoffman
- Monter Cancer Center-Division of Hematology Oncology, Northwell Health, Lake Success, New York, USA
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43
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Abstract
Wellens' syndrome is described as characteristic biphasic or symmetrical T-wave inversion with normal precordial R-wave progression and the absence of Q waves in the right precordial leads. It is seen during chest pain-free interval in a subset of patients with unstable angina. Wellens' syndrome is associated with critical stenosis of proximal left anterior descending (LAD) coronary artery. Similar characteristic ECG changes associated with causes other than LAD stenosis have been described as pseudo-Wellens' syndrome. In this case report, we present a young 22-year-old man who presented with characteristic Wellens' ECG changes in the setting of pulmonary embolism with right ventricular strain. T-wave inversion in right precordial leads is a well-recognised ECG manifestation of right ventricular strain; however, biphasic T waves in the setting of pulmonary embolism are rare. Pulmonary embolism was seen in our patient a week after starting risperidone. There is a reported association between antipsychotic drugs and increased risk of thromboembolism. Risperidone could have potentially contributed to the pulmonary embolism in our patient given the temporal association and absence of risk factors.
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Affiliation(s)
- Yub Raj Sedhai
- Internal Medicine, VCU School of Medicine, Richmond, Virginia, USA
| | - Soney Basnyat
- Internal Medicine, St. Mary Mercy Hospital, Livonia, Michigan, USA
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44
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Abstract
A case of acute dyskinesia in a 42-year-old man with a history of cocaine use and schizophrenia is described. He had discontinued clozapine approximately 1 month before presenting to the emergency department displaying signs of psychosis, with generalised choreiform and dystonic movements. Urinary toxicology was positive for cocaine. Clozapine treatment was reinitiated, and within 2 weeks the dyskinesia had subsided. Review of his records revealed two previous episodes of similar dyskinesia, both of which were temporally associated with cocaine use. Dyskinesia occurring in the context of cocaine use, and clozapine withdrawal-associated dyskinesia were considered to be the main differential diagnoses. A range of differential diagnoses should be considered in patients presenting with an acute-onset movement disorder who have a history of long-term exposure to antipsychotic medication.
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Affiliation(s)
- Alex James Berry
- Department of Psychiatry, Camden and Islington NHS Foundation Trust, London, UK
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45
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Abstract
The case of a 61-year-old female patient with a long-standing history of bipolar affective disorder treated medically with lithium therapy for the past two decades. In late 2012, the patient was diagnosed with hyperparathyroidism secondary to lithium therapy. The patient underwent parathyroidectomy in August 2013. During surgery, only two glands were conclusively located and removed. This resulted in a reduction in the patient's plasma total calcium levels and parathyroid hormone. The psychiatric management of the bipolar affective disorder was reviewed, and lithium discontinued as a result of the findings. Over the following year, a variety of different mood stabilisers were trialled, however none were found to successfully maintain the patient's mental health. In August 2014, the patient was admitted with a severe depressive relapse of her bipolar affective disorder. Her admission tests showed hypercalcaemia, which may also have contributed to her mood symptoms and mental state deterioration. The patient was reviewed by the endocrinology team and subsequently commenced on cinacalcet treatment (30 mg twice a day). Over the following months, the patient's plasma total calcium levels returned to within normal range. The patient's depressive symptomatology gradually improved with a combination of physical and pharmacological treatments.
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Affiliation(s)
- Michael Dixon
- Pharmacy, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Vikram Luthra
- Medical Psychotherapy Service, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Christopher Todd
- Department of Pharmacy, Bradford District Care NHS Foundation Trust, Bradford, UK
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46
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Abstract
Hypogonadotropic hypogonadism is a rare congenital disorder characterised by the deficiency and the absence of puberty and infertility. It is caused by the deficient production, secretion or action of gonadotropin-releasing hormone, which is the master hormone regulating the reproductive axis. Gonadotropin-releasing hormone or gonadotropin injections and testosterone replacement therapy are required in the treatment of this disorder. Psychiatric symptoms and disorders may be seen with the use of anabolic androgenic steroids. In this case report, we present a case report in which a patient had behavioural symptoms in childhood and develops bipolar disorder after testosterone replacement therapy. This patient was reached to the remission by increasing the doses of psychiatric drugs without interfering with hormonal therapy. It should be considered that patients receiving testosterone replacement therapy may develop bipolar disorder or trigger mood changes in bipolar mood disease, so behavioural and mood state changes should be closely followed in patients who have bipolar mood disease.
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Affiliation(s)
- Gulcin Elboga
- Department of Psychiatry, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Zeynel Abidin Sayiner
- Department of Endocrinology and Metabolism, School of Medicine, Gaziantep University, Gaziantep, Turkey
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47
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Bhamra M, Rajkumar AP, Ffytche DH, Kalafatis C. Successful management of persistent distressing neuropsychiatric symptoms by clozapine in a patient suffering from dementia with Lewy bodies. BMJ Case Rep 2018; 2018:bcr-2018-224710. [PMID: 30054321 DOI: 10.1136/bcr-2018-224710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Dementia with Lewy bodies (DLB) is the second most common neurodegenerative dementia associated with poor prognosis and high carers' burden. Neuropsychiatric symptoms worsen this prognosis and are a high source of distress for service users and their carers. However, there is currently insufficient evidence to support the pharmacological and non-pharmacological management of these symptoms. Acetylcholinesterase inhibitors are the first-line pharmacological option, but challenging risky behaviours may persist despite their use. Antipsychotic medications are indicated in such clinical scenarios, but there is very limited evidence to support the efficacy and safety of these medications for managing neuropsychiatric symptoms in DLB. Hence, we report an individual with DLB with severe distressing persistent visual hallucinations and agitation. After multiple treatment options had failed, clozapine was successfully initiated with substantial improvement in both clinical and functional outcomes. Further studies are warranted for evaluating the efficacy of clozapine in managing neuropsychiatric symptoms in DLB.
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Affiliation(s)
- Manraj Bhamra
- Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Anto P Rajkumar
- Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Dominic H Ffytche
- Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Chris Kalafatis
- Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, London, UK
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Sommer IEC, Kleijer H, Visser L, van Laar T. Successful treatment of intractable visual hallucinations with 5-HT 2A antagonist ketanserin. BMJ Case Rep 2018; 2018:bcr-2018-224340. [PMID: 29950360 DOI: 10.1136/bcr-2018-224340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Hallucinations, visual, auditory or in another sensory modality, often respond well to treatment in patients with schizophrenia. Some, however, do not and can be very chronic and debilitating. We present a patient with schizophrenia with intractable hallucinations despite state of the art care, including high-dose clozapine and transcranial magnetic stimulation. Based on the possible role of the 5-HT2A receptor in hallucinations, we treated her with the antihypertensive drug ketanserin, a 5-HT2A receptor antagonist.This significantly reduced her visual but not her auditory hallucinations, suggesting a possible role of the 5HT2A receptor in the pathophysiology of specifically visual hallucinations. This is the first time ketanserin has been described to successfully reduce visual hallucinations in a patient with schizophrenia.
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Affiliation(s)
- Iris E C Sommer
- Department of Psychiatry and Department of Neuroscience, Rijksuniversiteit Groningen (RUG), Universitair Medisch Centrum Groningen (UMCG), Groningen, The Netherlands.,Department of Psychology, Universitetet i Bergen Det Psykologiske Fakultet, Bergen, Norway
| | - Hidde Kleijer
- Department of Psychiatry and Department of Neuroscience, Rijksuniversiteit Groningen (RUG), Universitair Medisch Centrum Groningen (UMCG), Groningen, The Netherlands.,Department of Psychiatry, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Lucy Visser
- Department of Psychiatry, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Teus van Laar
- Department of Neurology, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
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Abstract
This paper describes a patient who presented with mania with psychotic features in the context of concomitant use of S-adenosyl-L-methionine (SAMe) and selective serotonin reuptake inhibitor (SSRI). The aim of this case report is to provide medical practitioners with a greater awareness of the possibility of a psychotic episode and/or mania manifesting with concurrent use of SAMe and SSRI.
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Affiliation(s)
| | - Ramandeep Gill
- Psychiatry, James Cook University College of Medicine and Dentistry, Cairns, Queensland, Australia
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50
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Abstract
Thiamine-responsive megaloblastic anaemia (TRMA) is a syndrome associated with megaloblastic anaemia, diabetes mellitus and sensorineural deafness, due to mutations in the SLC19A2 gene, which codes for a thiamine carrier protein. Oral thiamine supplementation is the main treatment. We report the case of a 25-year-old woman known for TRMA, who presented with pancytopenia (haemoglobin 7.6 g/dL, leucocytes 2.9×109/L, thrombocytes 6×109/L) revealed by dyspnoea. Investigations excluded coagulopathy, a recent viral infection, vitamin and iron deficiencies, and a malignant process. We later found out that thiamine treatment had been discontinued 5 weeks before, due to prescription error. Parenteral thiamine administration resulted in the recovery of haematopoiesis within 3 weeks. Pancytopenia is uncommon in patients with TRMA. Pre-existing medullary impairment caused by the patient's daily antipsychotic medications or the natural course of the syndrome may explain the severity of the laboratory findings in our patient.
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Affiliation(s)
- Virginie Moulin
- Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Francesco Grandoni
- Department of Hematology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Julien Castioni
- Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Henri Lu
- Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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