Piyush Das

Catatonia as a manifestation of tacrolimus-induced neurotoxicity in organ transplant patients: A case series

Tacrolimus has been associated with severe neurotoxicity in organ transplant patients. Catatonia can be a rare manifestation of tacrolimus-induced neurotoxicity as we report two cases of catatonia in solid organ transplant patients on tacrolimus. Catatonic symptoms completely resolved in these patients after reducing the tacrolimus dosage or switching it to alternative immunosuppressants. Catatonia symptoms in organ transplant patients should alert clinicians to look for tacrolimus-induced neurotoxicity despite normal serum tacrolimus levels and neuroimaging findings.

Obsessive-compulsive disorder after right temporal-lobe hemorrhage.

To the Editor: Obsessive-compulsive disorder (OCD) is a psychiatric illness characterized by persistent, intrusive, and senseless thoughts (obsessions) and urges to perform repetitive behaviors (compulsions) that interfere with functioning and/or cause distress. Although OCD secondary to various neurological lesions has been described, cerebral hemorrhage has rarely been associated with OCD. We present the first reported patient;

Psychosis Likely Induced by Hydroxychloroquine in a Patient With Chronic Q Fever: A Case Report and Clinically Relevant Review of Pharmacology

Received January 9, 2012; revised June 22, 2013; accepted June 24, 2013. From Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN. Send correspondence and reprint requests to Piyush Das, M.D., Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, 11203 Stokes Boulevard, Cleveland, OH 44104; e-mail: drpiyushdas@yahoo.com & 2014TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

Late-onset recurrent mania as a manifestation of Wallenberg syndrome: a case report and review of the literature

The aim of the present case report was to describe the late onset of recurrent mania in a patient after ischemic injury to the cerebellum and dorsolateral medulla.

PTSD in post-road traffic accident patients requiring hospitalization in Indian subcontinent: A review on magnitude of the problem and management guidelines

Traumatic events after a road traffic accident (RTA) can be physical and/or psychological. Posttraumatic stress disorder (PTSD) is one of the major psychological conditions which affect accident victims. Psychological issues may not be addressed in the emergency department(ED) immediately. There have been reports about a mismatch between the timely referrals from ED to occupational or primary care services for these issues. If left untreated, there may be adverse effects on quality of life (QOL) and work productivity. Hospital expenses, loss of income, and loss of work could create a never ending cycle for financial difficulties and burden in trauma victims. The aim of our review is to address the magnitude of PTSD in post-RTA hospitalized patients in Indian subcontinent population. We also attempted to emphasis on few management guidelines. A comprehensive search was conducted on major databases with Medical Subject Headings (MeSH) term ‘PTSD or post-traumatic stress’ and Emergency department and vehicle or road or highway or automobile or car or truck or trauma and India. Out of 120 studies, a total of six studies met our inclusion criteria and were included in the review. Our interpretation of the problem is that; hospital expenditure due to trauma, time away from work during hospitalization, and reduction in work performance, are three major hits that can lead RTA victims to financial crisis. Proposed management guidelines are; establish a coordinated triage, implementing a screening tool in the ED, and provide psychological counseling.

Verapamil for the Treatment of Clozapine-Induced Persistent Sinus Tachycardia in a Patient with Schizophrenia: A Case Report and Literature Review

Tachycardia (resting heart rate [HR] 4 100 min), a common side effect of clozapine treatment, can be concerning enough to deter the use of this gold standard treatment for severe and treatment-resistant psychotic patients. Adequate management of this side effect can permit continuation of this extremely effective treatment. To the best of our knowledge, this is the first case report describing suppression of clozapine-induced tachycardia with verapamil, a calcium channel blocker.

Post-Pump Chorea—Choreiform Movements Developing after Pulmonary Thromboendarterectomy for Chronic Pulmonary Hypertension Presenting as "Functional" Movement Disorder

Movement disorders are a group of diseases which affect ability to produce and control bodily movement. The movement disorders get labeled as “functional” in nature if organic cause could not be found after extensive medical work-up and features from the history and examination are inconsistent with a known neurologic problem. There is tendency to miss an organic cause of a movement disorder if it is too rare to attract much attention. This usually results in referral for psychiatric evaluation. The implications are devastating. The potentially treatable neurologic cause and disability due to distressing symptoms can go untreated, and incorrect mental health diagnosis can cause demoralization and stigmatization. We report here such a case where the patient was initially diagnosed with functional movement disorder but further evaluation and literature search revealed a rare neurologic condition called “post-pump chorea” syndrome.

Impact of Supplemental Oxygen on Obstructive Sleep Apnea of Infants

Treatment options may be limited for infants with obstructive sleep apnea when there is no surgically correctable upper airway lesion. We therefore evaluated, retrospectively, the efficacy of low-flow oxygen as a therapeutic option for infant obstructive sleep apnea. We reviewed the medical charts of 23 infants who had undergone a therapeutic trial of low-flow oxygen during polysomnography. Split-night polysomnography was used in 21/23 subjects while 2/23 had undergone two separate, full-night polysomnography sleep architecture and respiratory findings on the baseline polysomnogram segment that was obtained in room air were compared with the segment on low-flow oxygen (0.25–1 L/min). Wilcoxon signed rank or McNemar’s test were used as indicated for comparing apnea hypopnea index and measures of sleep architecture at baseline and with oxygen therapy. The mean (±SD) age of subjects was 4.8 (±2.7) months, with 52% being males. The median apnea hypopnea index fell from a baseline of 18 (range 7–43) to 3 (range 1–19; p = 0.001) on oxygen. The baseline median obstructive/mixed apnea index decreased from 2 (range 1–16) to 1 during oxygen therapy (range 0–1; p = 0.003). Additionally, a significant decrease in central apnea index (median interquartile range (IQR) 1 (0–2) vs. 0 (0–1), p = 0.002) was noted. Sleep efficiency remained unaffected, while O2 saturation (SaO2) average and SaO2 nadir improved on oxygen. We were able to confirm the utility of low-flow oxygen in reducing central, obstructive, and mixed apneas and improving average oxygen saturation in infants with obstructive sleep apnea (OSA).

Sertraline-Induced Hypersexuality in a Patient Taking Bupropion

To the Editor: Sertraline is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. Estimates of sexual dysfunction with SSRIs have been suggested to be between 30% and 50%, with some reporting up to 80%.1,2 Interestingly, there are a few reports of heightened sexual activity with SSRIs.3–7 We report the first case of sertraline-induced hypersexuality in a patient taking bupropion for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Case report. Mr A, a 55-year-old married white man, presented in 2006 for management of DSM-IV PTSD and MDD. His symptoms were inadequately controlled with bupropion (extended release 100 mg daily). Due to limited evidence on benefit of bupropion in PTSD, the bupropion dose was not increased further. Instead, sertraline was added per US Food and Drug Administration (FDA) recommendation for PTSD, and the dose was titrated to 100 mg daily. On a return visit, Mr A reported improvement, but his wife expressed concern about his having heightened sexual desire and increased demands to have sexual intercourse, resulting in spousal distress to the point of marital discord. The patient confirmed this and added that his erections had been lengthier and firmer than ever before. There was no evidence of priapism. Both the patient and his wife strongly attributed this heightened sexual desire to introduction of sertraline, since this increased desire was nonexistent when he took bupropion alone. There was no evidence of hypomania/mania. Substance use, medical conditions, and medicines used to enhance sexual functioning were ruled out. The patient discontinued sertraline, and hypersexuality gradually resolved over a span of 1 month without concomitant worsening in his PTSD and MDD symptoms. He was then maintained on bupropion monotherapy. The mechanism of SSRI-induced sexual dysfunction is not clear, but serotonin receptors 5-HT2 and 5-HT3, neurotransmitters such as dopamine, and prolactin have been implicated.8,9 Intriguingly, SSRIs, including fluoxetine and paroxetine, have been associated with hypersexuality in previous case reports.4,5,7,10–13 Dose-dependent incidence of hypersexuality has been described in a patient taking fluoxetine, for whom symptoms emerged within 2 days of increasing the fluoxetine dose from 20 mg to 40 mg daily and subsided completely with reduction to 20 mg daily.10 The hypersexuality resolved after discontinuation of SSRI treatment in other cases.4,5,7 Our patient never complained of sexual stimulation on bupropion monotherapy despite the favorable effect of bupropion on sexual functioning.14 The emergence of hypersexuality in our patient on the addition of sertraline may be an independent side effect of sertraline or may be due to the synergistic action of bupropion and sertraline. Sertraline is not an exclusively serotonergic agent but also acts on norepinephrine and dopamine receptors.15 A recent preclinical study showed that sertraline increases extracellular levels of dopamine in the nucleus accumbens and striatum of rats.16 Similarly, fluoxetine has been shown to increase synaptic dopamine level.17 These data may support hypersexuality as an independent side effect of certain SSRIs, most likely due to their prodopaminergic action. There is 1 previous case report of hypersexuality caused by combination of bupropion and sertraline18 resulting after bupropion was added for sertraline-induced sexual dysfunction. Our case had the reverse sequence. Inhibition of metabolism of bupropion by sertraline19 can potentially explain hypersexuality. There is also evidence of inhibition of metabolism of sertraline by bupropion involving cytochrome P450 2D6.20 Hence, blood levels of both bupropion and sertraline can potentially rise in a patient receiving this particular combination. Although the mechanism of SSRI-induced hypersexuality is still speculative, SSRIs have been associated with hypersexuality both independently and in combination with bupropion. Clinicians should be aware of hypersexuality as a rare but distressing side effect of SSRI treatment.