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Toxic psychosis following cycloplegic eyedrops.

A case of toxic psychosis due to cycloplegic eyedrops is reported. The characteristic mental symptoms of atropine intoxication include confusion with vivid visual hallucinations, restlessness, muscular incoordination, and later emotional lability. These symptoms and a short period of retrograde amnesia occurred in our patient. The adverse drug reaction was confirmed following rechallenge. The possible preventive measures against intoxication caused by atropine eyedrops are described. All healthcare professionals should be aware of the possible temporal relationship between the appearance of pathology and the administration of a drug.

Aged↗

[A case of volatile solvent psychosis accompanied with multiple neurological and psychological symptoms].

A case of psychosis accompanied with variable symptoms induced by chronic volatile solvent inhalation is reported in this study. The patient was a 27-year-old male who had abused volatile solvents for 15 years, and was sent to the hospital because of a tonic-clonic seizure. Severe psychomotor excitement was observed on the first day and the 7th day after admission. After 10 days of admission, we observed visual transformation and hyperthermia, which suggested acute toxic symptoms due to a volatile solvent. Furthermore, symptoms such as incoherence, delusions of persecution, and catalepsy were also observed in this case. There have been few reports of multiple neurological and mental symptoms appearing in cases of volatile solvent psychosis. Although we sometimes experience cases of solvent abuse with acute mental symptoms and recurrent excitement after sedation, such symptoms are not always observed because of flashback in the strict sense. Therefore, careful early treatment should be employed to prevent 'secondary excitement'.

Adult↗

Hyponatremia and rhabdomyolysis: a possible relationship.

A 40-year-old schizophrenic presenting with an acute toxic psychosis was found to be severely hyponatremic with a serum osmolality of 217 mOsm/kg. The patient was combative and required physical restraints. Shortly after admission the patient's serum transaminase level was elevated, and the next day the CPK value was 175,000 IU. In addition, his serum and urinary myoglobin levels were markedly raised. Shortly after rhabdomyolysis was diagnosed, the patient developed reversible acute renal failure presumably secondary to the myoglobinuria. This report examines the possibility that the severe hyponatremia and hypoosmolality caused his skeletal muscles to become potassium depleted, leading to rhabdomyolysis during the stenuous exercise involved in his battling the restraints.

Adult↗

[Toxic psychosis as an acute manifestation of diphenhydramine poisoning].

Acute manifestations of a toxic psychosis with optic and tactile hallucinations developed in a 46-year-old woman after having swallowed a total of 1600 mg diphenhydramine with suicidal intent. The acute hallucinations lasted for eight hours and then disappeared completely without any treatment. The patient reported a series of highly plastic and rapidly changing sensations of various insects, such as spiders, beetles and ticks, without any equivalent in reality, which to the patient seemed absolutely real throughout the psychotic episode. Diphenhydramine intoxication is to be differentiated from two organic psychiatric diseases, the dermatozoa delusion syndrome and alcoholic delirium.

Acute Disease↗

The Agent Orange controversy after the Evatt Royal Commission.

The Evatt Royal Commission Report on the Use and Effects of Chemical Agents on Australian Personnel in Vietnam has authoritatively rejected the substantive claims that were made by the Vietnam Veterans' Association of Australia about the adverse effects of exposure to phenoxy herbicides in Vietnam on the health of Vietnam veterans and their families. The Commission concluded that Vietnam veterans were not exposed to toxic levels of chemicals in Vietnam; that they are not at any increased risk of fathering children with birth defects, or contracting cancer; and that, although they have slightly higher rates of psychiatric disorder, heart disease, alcoholism and alcohol-related disease, these effects are unconnected with exposure to chemicals in Vietnam. The reasons for these findings deserve to be given the widest possible publicity. Only by doing so is there any prospect of dissolving the misapprehension that Vietnam veterans have been poisoned by herbicides.

2,4,5-Trichlorophenoxyacetic Acid↗

CNS adverse events associated with antimalarial agents. Fact or fiction?

CNS adverse drug events are dramatic, and case reports have influenced clinical opinion on the use of antimalarials. Malaria also causes CNS symptoms, thus establishing causality is difficult. CNS events are associated with the quinoline and artemisinin derivatives. Chloroquine, once considered too toxic for humans, has been the antimalarial of choice for 40 years. While a range of serious CNS effects have been documented during chloroquine therapy, the incidence is unclear (extrapyramidal symptoms occur with an incidence of 1 in 5000). Amodiaquine has a higher incidence of mild CNS effects than chloroquine. Mefloquine therapy causes dose-related transient dizziness. Serious CNS events during mefloquine therapy occur in 1:1200 Asians and 1:200 Caucasians/Africans. Risk factors include dosage, concomitant drug use/interactions, previous history of a CNS event and disease severity. Retreatment (within a month) increases the risk in Asians 7-fold. Studies indicate that the frequency of serious CNS events with mefloquine prophylaxis (1:10,000) is similar to that with chloroquine (1:13,600). Quinine causes cinchonism at standard therapeutic doses. High-tone hearing loss occurs, but irreversible auditory or ocular effects are very rare. The artemisinin derivatives are associated with dose-dependent brain lesions in rodent, canine and nonhuman primates. At low doses, histological injury has been demonstrated, without clinical neurological signs. No significant toxicity has been reported in humans. Other antimalarial drugs are seldom associated with CNS adverse events. Data do not suggest a need to diminish the correct use of the quinoline derivatives. Irreversible effects are extremely rare and usually associated with overdosing or prior history of a serious CNS event. Concomitant therapeutic use of 2 drugs from the same family, or retreatment with the same drug, should be avoided. Onset of drug-associated serious CNS events requires drug discontinuation and future avoidance of the drug.

Adult↗

Effect of drugs used in psychoses on cerebral dopamine metabolism.

1. Chlorpromazine 15 mg/kg, given daily to cats for 2 weeks, produced a rise in homovanillic acid (HVA) content of the caudate nucleus, whereas the same dose of thioridazine lacked this effect. Of these two drugs, only chlorpromazine causes a high incidence of drug-induced Parkinsonism in man.2. In the mouse, chlorpromazine, thioridazine and haloperidol increased striatal concentrations of HVA and accelerated the disappearance of dopamine (DA) after inhibition of catecholamine synthesis with alpha-methyltyrosine. Low doses of the three compounds increased, whereas high doses reduced, the concentration of DA in the striatum. In their effects on the DA metabolism of the mouse, chlorpromazine and thioridazine had the same potency, but haloperidol was between 10 and 100 times more active than the other two drugs. In producing hypothermia and sedation, the three compounds were equiactive.3. Oxypertine, another drug apt to produce Parkinsonism in man, caused a severe reduction in striatal DA and hypothalamic noradrenaline (NA). Though the clinical signs produced in the mouse were indistinguishable from those seen after the same dose of chlorpromazine, the biochemical changes in the brain were thus quite different.4. Though all the drugs used caused temporary motor disabilities in animals, these bore no resemblance to human Parkinsonism, even when treatment was continued for 7 weeks or more as it was in cats and monkeys. The latter were treated with chlorpromazine 7.5 mg/kg daily, a dose chosen to avoid loss of weight and which may have been too small to produce toxic side-effects. It caused no changes in striatal DA turnover.5. Even at the high dose of 50 mg/kg, phenoxybenzamine did not increase DA turnover in mouse brain, but it sedated the mice as did the tranquillizers.6. Atropine sulphate, 25 mg/kg, reduced the HVA content of mouse striatum and partially antagonized the rise in HVA produced by phenothiazines. The effect was surmountable. Possible modes of action of atropine are discussed.7. At present we know of two types of biochemical changes which may occur in the brain of animals after treatment with drugs apt to cause Parkinsonism in man: a loss of cerebral catecholamines, as seen after reserpine or oxypertine, or an increase in turnover of DA as after phenothiazines and butyrophenones.

Animals↗

Withdrawal psychosis: a study of 30 consecutive cases.

A study was carried out of 30 consecutive patients with withdrawal psychosis who in the period 1972 to 1975 were admitted to a psychiatric department or were attended by the department while hospitalized in a somatic department. There was a clear majority of women among cases of psychosis following drug withdrawal (15 as against four) and a clear majority of men among cases of psychosis following alcohol withdrawal (nine as against two). Competing pathogenetic factors could be considered present in most cases in the last mentioned group. In most cases the abrupt cessation took place in conjunction with admission to hospital, most frequently surgical cases or cases of acute drug toxication. In other cases abrupt cessation was decided upon by the patient himself. Frequently predelirium treatment was either omitted or was given in the form of neuroleptics. Approximately a quarter of the patients initially denied their abuse. The study indicates that withdrawal psychosis can make its debut or become manifest at so late a stage as about the 14th day of the withdrawal phase following use of benzodiazepines and d-propoxiphene. It is further indicated that abrupt cessation of benzodiazepines taken in "therapeutic" doses for several years in some instances can give rise to a withdrawal psychosis.

Adult↗

Disorders of attention: a frontier in neuropsychology.

There is an extensive behavioural neurological literature on so-called unilateral attentional disorders, but a striking paucity of papers on global disorders of attention, i.e. confusional states. However, confusional states are distinctive because: (1) they are the most common disturbance of the higher functions in clinical practice, by orders of magnitude; (2)they are the only disturbance of the higher functions from which all normal subjects have suffered; (3) they have characteristic clinical manifestations; (4) they are frequently misdiagnosed as progressive dementias, aphasia, memory disorders, and psychoses; (5) they are the only disturbance of the higher functions that commonly cause patients to produce statement that appear to be extremely witty; (6) they can be readily studied experimentally; (7) they are the most common cause of unconcern with or denial of illness. There are almost certainly several different forms of confusional state depending on the aetiology, the rate of development, the age, and the anatomical systems involved, but little classification has yet been carried on. Confusional states are most simply defined as disorders in which there is a loss of the normal coherence of thought or action. Among the striking clinical features are: (1) failure to pay attention, excessive distractibility, or failure to shift attention; (2) paramnesias, i.e. distortions of memory; (3) reduplicative phenomena, 'wild' paraphasias with 'propagation' of error, alterations of mood in many different directions; (4) isolated or predominant disturbance of writing (the most common cause of pur agraphia); (5) unconcern with or denial of illness; (6) apparently playful behaviour. While confusional states are usually attributed to 'global involvement of the brain' as a result of metabolic or toxic disorder, there are in fact many cases produced by focal infarctions inthe right hemisphere, which, in the experience of my department, is one of the commonest effects of cerebrovascular disease. Brief reference is made to the prognosis, and to the theoretical significance for cerebral dominance and the evolutionary development of cerebral dominance in non-human species.

Amnesia↗

[Various aspects of the clinical picture and differential treatment of patients with alcoholic delirium].

A total of 775 patients with alcoholic delirium were examined. Alcoholic delirium was found to have undergone a certain pathomorphosis, manifesting in a more pronounced somatic pathology and less representative hallucinational symptomatology. A number of new variants of alcoholic delirium are presented along with the typical and previously described ones. These include: (a) short-term (within 24 hours) gross neurological symptomatology due to a transient impairment of the cerebral blood circulation following the toxic impact of alcohol on the cerebral vessels; (b) alcoholic delirium with a longer transient impairment of the cerebral blood circulation for as long as three months; (c) alcoholic delirium with prolonged subclinical symptomatology and a negligible effect on the patients' behaviour which is subsequently transformed into a sharp psychomotor excitement, epileptiform paroxysm, etc., and finally into a comatose state caused by brain edema. Treatment should be differential, with due regard for the severity of the disease, and aimed at the recovery of the normal sleep pattern, detoxification as well as prevention and control of grave somatic complications.

Alcohol Withdrawal Delirium↗

Toxic psychosis induced by phenothiazine administration in patients with chronic renal failure.

Adverse reactions to phenothiazines have not been commonly recognized in patients with chronic renal failure. We wish to report a characteristic acute psychosis as a complication of phenothiazine use in such individuals. Four patients with chronic renal failure requiring hemodialysis were given doses of chlorpromazine ranging from 100--1000 mg over time intervals varying from 2--7 days. All developed extreme restlessness, auditory and visual hallucinations, and episodes of belligerent behavior. A fifth patient treated with promethazine developed a similar psychosis. Each became ill shortly after the initiation of phenothiazine therapy. All improved slowly after cessation of the drug. Hemodialysis in four patients did not appear to affect the course of the illness. The use of phenothiazines in patients with chronic renal failure is cautioned.

Aged↗

Long-term psychological and neurological complications of lindane poisoning.

A thin, healthy, partial-vegetarian, white female, who was exposed to three doses of lindane (through the application of Kwell), developed a severe case of long-term lindane poisoning. Review of the literature suggests that her toxicity was so severe because of the repetitive nature of her exposure and the fact that she was partly protein restricted when first exposed. She developed profound central nervous system toxicity, as well as skin and gastrointestinal changes, that persisted for 20 months. She was treated with high doses of Valium. It was noted that every time her Valium was diminished below a critical level, her symptoms tended to recur until she had adequately cleared the lindane from her system. We believe this is the longest term of poisoning reported following exposure to an organochloride insecticide. Her symptoms are well explained by the physiology of these compounds as described in the literature. The case is important, for it represents the longest persistence of symptoms clearly associated with poisoning by the potent gamma isomer of BHC-lindane.

Administration, Topical↗

Mefloquine prophylaxis: an overview of spontaneous reports of severe psychiatric reactions and convulsions.

Since the time of its introduction in 1985, mefloquine (Lariam) has been used extensively for malaria prophylaxis. The international Drug Safety Department of the manufacturer gathered all spontaneous adverse drug reactions reported in association with this drug from all available sources and monitored the literature on a world-wide basis. The serious neurologic and psychiatric adverse events reported in association with Lariam prophylaxis from the time of introduction until May 1991 were reviewed. During this time, 59 serious neurologic and psychiatric adverse reactions were reported as follows: 26 convulsions, 12 depressions, 20 psychotic episodes, and one toxic encephalopathy; none were fatal. While spontaneous reporting systems are biased by under-reporting, they provide useful instruments for analysis of clinical risks factors. The neurologic and psychiatric adverse events reported in association with mefloquine prophylaxis were of the same types as those reported with other quinine derivative antimalarials. The precise mechanism of serious neurologic and psychiatric reactions is unknown. The only patient population identified at this time as having an increased risk of developing these serious reactions to mefloquine are persons with a history of seizures or manic-depressive illness. Mefloquine prophylaxis should not be prescribed to such patients.

Adolescent↗

[A case of toxic psychosis caused by bromocriptine].

We present a short review of literature concerning the problem of bromocriptine-induced psychosis A case of toxic psychosis following treatment on bromocriptine in an acromegalic patient who had previously undergone hypophysectomy is also reported. On two occasions after having received low doses of bromocriptine for several months, the patient developed a psychotic syndrome characterized by violent behaviour, auditory hallucinations, paranoid misinterpretation, threatening delusions and depersonalization, which lasted several weeks. On treatment with neuroleptics, the symptoms gradually remitted. In the context of the reviewed literature, an outstanding feature of the case is the absence of psychiatric history, which is not frequent, but not unlikely in the published case-reports. This reassures the authors' on the unespecificity of psychiatric syndromes, broadly discussed in our own and other colleges' references.

Acromegaly↗

Elevated mortality from nonalcohol-related chronic liver disease among female rubber workers: is it associated with exposure to nitrosamines?

BACKGROUND: Despite several case reports describing liver toxicity of nitrosamines and the fact that some N-nitroso compounds are used to induce cirrhosis of the liver in animal models, this association has not been investigated in epidemiological studies. METHODS: A cohort of 2,875 female rubber workers who were active on January 1, 1976, or hired thereafter, and who had been employed for at least 1 year in one of five plants producing tires or technical rubber goods was followed for mortality from January, 1976, through December, 1991. Work histories were reconstructed using routinely documented "cost center codes" and classified into six work areas. Age and calendar year standardized mortality ratios (SMR) and 95% confidence intervals (95% CI) were calculated and stratified by plant, work area, year of hire, and years of employment in the respective work area. RESULTS: The excess mortality from cirrhosis of the liver was most pronounced for nonalcohol-related cirrhosis of the liver (ICD-9 571.4-571.9: 10 deaths, SMR 202; 95% CI 97-372). Mortality from alcohol-related cirrhosis of the liver (ICD-9 571.0-571.3: 3 deaths, SMR 153; 95% CI 31-446) and from other alcohol-related diseases (organic psychoses, injury, and poisoning) was not statistically significantly elevated. All 10 cases of nonalcohol-related cirrhosis had worked in production of technical rubber goods (SMR 279; 95% CI 134-514) and risks increased with earlier years of hire and with longer duration of employment in this work area. DISCUSSION: Although our results must be interpreted with caution, they suggest that the observed excess deaths from cirrhosis of the liver are associated with occupational risk factors. In light of additional evidence from case reports and animal data, exposure to nitrosamines may be a plausible risk factor for the observed excess mortality.

Adult↗

[Cocaine "mules"].

We present 2 cases of "body-packer" syndrome (BPS) in which the "mules" carrying the packages of narcotics arrived at Ben-Gurion Airport presented symptoms of acute cocaine intoxication due to the bursting of packages of narcotics they were transporting within their gastro-intestinal systems. Acute cocaine overdose due to sudden massive release of the drug into the digestive system in BPS, may cause psychosis, convulsions and eventually death. Blood levels of cocaine between 0.25 and 5 mcg/ml are toxic and occasionally lethal. When a package bursts within the digestive tract of a smuggler or blocks the intestines, an immediate laparotomy is necessary to evacuate the "ovules" and the remains of the drug from stomach and intestines. Patients merely suspected of being body packers can be diagnosed by physical examination and by means of various imaging methods. They can be conservatively treated with fluids and mild laxatives and kept under close supervision until the remaining packages are naturally discharged. Sudden onset of psychotic behavior in travelers from South America or other drug-producing countries should raise suspicion of body-packer syndrome. The relevant authorities should therefore be aware of the symptoms and consider their potentially dangerous outcome.

Adult↗

Efficacy of clozapine compared with other antipsychotics in preventing NMDA-antagonist neurotoxicity.

The focus of this article will be on toxic symptoms associated with blockade of the N-methyl-D-aspartate (NMDA) subtype of the glutamate receptor. We have been studying two parallel phenomena: NMDA-antagonist neurotoxicity (NAN) in rats and NMDA-antagonist psychotogenicity (NAP) in humans. These phenomena have a common denominator--NMDA receptor hypofunction, which is putatively a mechanism operative in schizophrenia. We have found that the NAN reaction in rats can be prevented by specific drugs that prevent NAP in humans and by certain antipsychotic agents, including clozapine, that ameliorate symptoms in schizophrenia. By studying mechanisms by which clozapine prevents the NAN reaction in rats, we hope to gain insight into mechanisms by which clozapine or other atypical antipsychotics ameliorate symptoms in schizophrenia.

Adolescent↗

Thallium poisoning presenting as paresthesias, paresis, psychosis and pain in abdomen.

Due to involvement of multiple systems, thallium poisoning is notorious for complexity and seriousness as symptoms of toxicity are non-specific and diverse. Alopecia and painful neuropathy are its cardinal features, others being gastrointestinal disturbances, encephalopathy, tachycardia, ataxia, hepatorenal and cardiac damage etc. We report a case of thallium poisoning who presented initially with gastrointestinal symptoms and later developed neurological features (peripheral neuropathy and delirium). Various diagnoses were entertained in this case and thallium poisoning was suspected only after he developed alopecia and neuropsychosis. He made a significant recovery by conservative management in spite of delay in diagnosis. We conclude that a high level of suspicion should be kept for thallium poisoning, especially in patients with painful, peripheral neuropathy and gastrointestinal symptoms which appear earlier than alopecia, since prognosis is more rewarding with early diagnosis, leading to complete recovery.

Abdominal Pain↗