Ranjita Santra

Suicidality and Suicide Attempt in a Young Female on Long-Term Sertraline Treatment

A 22-year-old woman who was on sertraline 50 mg oral tablets once daily for 2 years for treatment of major depression took 30 such tablets (1500 mg) in a fit of rage, with a suicidal intent. She presented to the Emergency Department of a Tertiary Care Hospital with tachycardia, tachypnea, hypertension, tremors, agitation, confusion, vomiting, and hyperthermia. The patient was admitted and treated symptomatically, and sertraline therapy was discontinued. The unwanted effects subsided within 48 h and she recovered uneventfully within 72 h. This case report describes an unsuccessful attempt of suicide with sertraline overdose in a patient on long-term sertraline therapy and underlines the importance of close monitoring of such patients.

Fixed Drug Eruption due to Fluconazole: Not so uncommon Now-a-days.

Sir, Fixed drug eruptions (FDEs) represent the most common cutaneous adverse drug reaction which is seen in the Indian scenario [1]. FDE is a distinctive drug-induced dermatosis with a characteristic recurrence at the same sites of the skin or mucous membrane, which occurs after repeated administrations of the causative drug [2]. It was first described by Bourns in1889; five years later, it was termed by Brocq as “eruption erythemato-pigmentee fixee” [3]. The most common drugs which cause FDE are antibiotics, followed by nonsteroidal anti-inflammatory drugs (diclofenac, aspirin, naproxen, and ibuprofen) [2]. Fluconazole is one of the most common drugs which is used in dermatology practice. We are reporting an FDE which occurred secondary to fluconazole intake. A 22-year-old woman received five doses of fluconazole (150 mg) orally, once a month, for recurrent vaginal candidiasis. A red erythematous macule which measured approximately 2 (two) centimetres in diameter, with well-defined and raised margins, appeared on the medial side of her right popliteal fossa, that was associated with burning and itching, four hours after she had taken her second dose of fluconazole. It faded, but a violet pigmentation developed after a week. A month later, she again developed two macules of similar dimensions within four hours of intake of another fluconazole dose. One of the lesions developed on exactly the same site where another had developed in the earlier episode and the other developed in the left popliteal fossa. After one week, the patches faded and hyperpigmented areas developed on the affected areas. Our differential diagnosis included fixed drug eruption and erythema multiforme. Although fixed drug eruption is primarily a clinical diagnosis, we conducted an oral challenge test. An oral challenge test with fluconazole (150 mg) was conducted 4 weeks later and it showed similar signs, three hours after intake of the drug. A local provocation test was performed with 10% fluconazole in petrolatum on the left pigmented area and with 10% fluconazole in ethanol on the right pigmented area. For comparison, the same compounds were tested on normal skin of her back. After 15 hours, two red patches developed on both sides of her legs and none developed on her back. A skin biopsy specimen taken from the left popliteal area revealed a lichenoid infiltrate, a basal cell vacuolization, dermal melanophages and a superficial perivascular lymphocytic infiltrate, which were consistent with features of FDE. The drug was dechallenged and the patient was treated antihistaminics and steroids. Contrary to this case, most of the previous studies done on FDEs caused by drugs had demonstrated higher occurrences in men as compared to those seen in women [4]. In the previous studies, all female patients were prescribed fluconazole for vaginal candidiasis, while male patients were prescribed fluconazole for Candida balanitis [5]. Cross-reactions may occur with structurally related agents such as itraconazole [6]. In almost all the cases, eruptions had occurred after a couple of drug administrations [7,8]. The only common medication which was used by the patients was fluconazole. The sites which were most affected for eruptions were limbs, palmar and plantar areas, as well as the oral cavity and lips [5–8]. Fluconazole is a commonly used antifungal agent, and a fixed drug eruption should be considered as a possible adverse effect of its use. This case highlights the importance of taking a comprehensive history of medication use and construction of a medication diary by the patient, to ascertain the occurrence of the eruptions after self-administering doses of fluconazole, when cutaneous adverse reactions are being examined.

Rosuvastatin induced periorbital tremor in a case of familial hypercholesterolemia

Rosuvastatin is an anti-lipaemic drug belonging to the class of statins that competitively inhibits hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase that catalyzes the conversion of HMG-CoA to mevalonic acid, the rate-limiting step in cholesterol biosynthesis. Cholesterol lowering agent myopathy (CLAM) is well recognized among physicians and patients. Less well known are the small number of patients on statins who have shown signs of peripheral neuropathy, either in addition to or separately from CLAM. Here we report a case of a 45-year-old lady who stared experiencing periorbital tremors shortly after introduction of rosuvastatin. While the pathophysiology of statin-induced myopathy remains unclear, we hope that this case will encourage others to report similar symptomatology, perhaps enabling to gain more insight on the cases of iatrogenic myopathies. Hence, pharmacogenetics study may prove to be useful for personalized therapy.

Nonsteroidal anti-inflammatory drug (NSAID) associated fixed drug eruption (FDE) in children attending dermatology OPD of a tertiary care hospital of Eastern India: a cross-sectional observational study

Background: Although extensively studied in adults, Nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity in children, especially in young children, remains a poorly defined area in both its clinical and epidemiologic aspects. Methods: The present observational study was conducted in the department of Dermatology of a tertiary care hospital in Eastern India. Twenty children (20) were screened with suspected NSAID-associated fixed drug eruption (FDE) in the outpatient department. A thorough history taking and clinical examination was performed for each of the cases of FDE. These cases were then managed conservatively after discontinuation of the suspected medication. Rechallenge with the putative offending drug was not done due to ethical reasons. WHO-UMC Causality Assessment criteria and Naranjo probability scale were used for causality assessment of each of the cases of FDE. The severity of reported reactions was assessed by using Modified Hartwig and Siegel Scale and Preventability of the ADRs was assessed by Modified Schumock and Thornton Scale. Results: Patients aged between 5 to 12 years and with a male preponderance of 3:2. The offending NSAID was ibuprofen for 8 of the patients, paracetamol and diclofenac for 4 each and ketorolac for 4 of the patients. These patients were prescribed the offending drugs for fever, rheumatoid arthritis and minor trauma. For each patient, history and clinical signs was consistent with the diagnosis of drug-induced FDEs. Causality assessment for each of the cases revealed ‘possible’ association predominantly (80%). Severity of the suspected ADR (adverse drug reaction) assessed using Modified Hartwig and Siegel Scale, revealed that the ADRs were mild(30%) to moderate (70%) in severity and of ‘probable’ preventibility (90%). Conclusions: 20 new cases of NSAID-induced FDEs over a period of 6 months suggest that this is not a rare entity as was presumed. There is a growing need for a strict monitoring of such off label offending drugs, known to cause ADRs especially among pediatric patients to ensure safe and rational therapeutics.

Orlistat-induced acute pancreatitis in a type II diabetic and hypothyroid young woman : A case report

Background: Orlistat is an anti-obesity drug that acts by inhibiting pancreatic and gastric lipase in the gastrointestinal tract. It has been linked to rare instances of acute pancreatitis, some of which have been severe. Case Report: A 31-year-old obese woman was prescribed orlistat 120-mg capsule three times a day with each main meal containing fat for 6 months. She developed acute abdominal pain and vomiting with epigastric tenderness 5 weeks after starting anti-obesity therapy. Serum lipase and computed Tomography (CT) scan of the patient suggested the presence of acute pancreatitis. The patient was hospitalized; orlistat was stopped and she was treated symptomatically. A diagnosis of drug-induced pancreatitis was made following exclusion of other possible factors precipitating pancreatitis. Conclusion: This case report suggests that orlistat can trigger drug-induced acute pancreatitis in some cases and clinicians should be vigilant about it. A total of 99 cases of orlistat-related pancreatitis have been reported to the US Food and Drug Administration (FDA), but no causative link has been found in the clinical trials. It is therefore not in the list of adverse drug reactions of orlistat.

Fluvoxamine Plays an Integral Role in the Alteration of Sexual Behavioral Pattern more in Females than Males.

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