Citalopram-induced severe hyponatraemia with coma and seizure. Case report with literature and spontaneous reports review

Numerous case reports of hyponatraemia followed increasing use of selective serotonin re-uptake inhibitors (SSRIs) but this adverse effect was only rarely observed in relation to citalopram. We report a case of severe hyponatraemia associated with deep coma, seizure, atrial fibrillation and muscle damage in a 92-year-old woman after only two doses of citalopram, and review 14 cases previously published in the literature and 28 cases spontaneously reported to Australian Drug Reaction Advisory Committee (ADRAC). The data presented suggest that citalopram, as well as SSRIs may cause hyponatraemia secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The majority of symptomatic cases occurred in elderly patients (79% were older than 70 years) and in women (74%). Polymedication and concomitant use of another psychotropic drug or thiazide diuretic may precipitate and/or augment the development of hyponatraemia/SIADH. In 84% of cases, the hyponatraemia associated with citalopram was detected during the first month of treatment. High level of suspicion, close and careful monitoring of serum sodium concentration particularly in elderly patients and especially in the first month of therapy with citalopram may reduce the incidence of this serious and likely not rare adverse effect.     

A survey of psychotropic medications in the United States.

The range of psychotropic medications available in the U.S. for the treatment of serious mental illnesses is limited. Many agents have been "me too" drugs, offering primarily side-effect differences, instead of new indications or mechanisms. As a result, patients refractory to the original drugs are not helped. Other patient populations (both mentally ill and addicted) have "fallen through the cracks" of the current U.S. psychotropic drug development process. The recent approval of chlorimipramine and clozapine demonstrates that real benefits for U.S. patients can be realized from judicious introduction of non-U.S. drugs. Many more psychotropic drugs developed and used in other countries are not available in the United States. Industrial and regulatory obstacles could be surmounted by the legislative innovation proposed. This survey identifies some specific non-U.S. drugs of interest.     

Risk of seizures associated with psychotropic medications: emphasis on new drugs and new findings

Psychotropic medications in the classes of antidepressants, antipsychotics and mood stabilisers have been recognised in the literature and clinical settings as having high epileptogenic potential. Among these three classes, clozapine, tricyclic antidepressants (TCAs) and lithium are agents that clinicians have historically recognised as precipitants of drug-induced seizures. There are few reports that review the epileptogenic risk of newer psychotropic agents; in this qualitative review, the authors provide an update on the most recently published reports on seizures associated with antidepressants, antipsychotics, mood stabilisers, anxiolytics and sedative-hypnotics. In general, the epileptogenic risks of the newer psychotropic agents appear to be quite low as long as dosing strategies are consistent with recommended guidelines. Whilst newer psychotropic medications appear to be safe in patients with epilepsy, few studies have specifically addressed this population. In addition, the potential for drug interactions between antiepileptic drugs and psychotropics may be substantial with certain agents. For example, many psychotropes are both substrates and inhibitors of cytochrome P450 (CYP450) isoenzymes, whilst many antiepileptic drugs are both substrates and inducers of CYP450 activity. Every attempt should be made to minimise potential interactions when these agents are concomitantly administered.     

Risk of seizures associated with psychotropic medications: emphasis on new drugs and new findings

Psychotropic medications in the classes of antidepressants, antipsychotics and mood stabilisers have been recognised in the literature and clinical settings as having high epileptogenic potential. Among these three classes, clozapine, tricyclic antidepressants (TCAs) and lithium are agents that clinicians have historically recognised as precipitants of drug-induced seizures. There are few reports that review the epileptogenic risk of newer psychotropic agents; in this qualitative review, the authors provide an update on the most recently published reports on seizures associated with antidepressants, antipsychotics, mood stabilisers, anxiolytics and sedative-hypnotics. In general, the epileptogenic risks of the newer psychotropic agents appear to be quite low as long as dosing strategies are consistent with recommended guidelines. Whilst newer psychotropic medications appear to be safe in patients with epilepsy, few studies have specifically addressed this population. In addition, the potential for drug interactions between antiepileptic drugs and psychotropics may be substantial with certain agents. For example, many psychotropes are both substrates and inhibitors of cytochrome P450 (CYP450) isoenzymes, whilst many antiepileptic drugs are both substrates and inducers of CYP450 activity. Every attempt should be made to minimise potential interactions when these agents are concomitantly administered.     

Impact of psychotropic medications on simulated driving: a critical review

Driving a motor vehicle is central to the functional autonomy of patients with psychiatric illnesses. There have been many studies of the deleterious effects of psychotropic medications such as benzodiazepines, typical antipsychotics and tricyclic antidepressants (TCAs) on human motor skills; however, in the literature little attention has been paid to how such impairment affects driving ability. Computerised driving simulators offer a laboratory-based method of assessing the effects of specific psychotropic medications on driving abilities, in a standardised, controlled and safe manner. The purpose of the present article is to review research undertaken to-date on the effects of psychotropic medications on computer-simulated driving. A search of various databases, including MEDLINE, EMBASE and PsycInfo, was conducted. Forty-one articles assessing the impact of psychotropics on computer-simulated driving were identified. The pooled total number of subjects assessed in these simulator studies was 1336 (mean sample size 30.36 [SD 35.8]). The most common outcome measures in the various studies were speed, steering, deviation from lateral position (tracking, lane drifting), reaction time or braking accuracy, driving errors (e.g. errors in turning, coordination, gap acceptance, signalling, following distance) and vehicle collisions. The results of the studies were quite variable; however, the most common drug-related impairments included those of tracking and reaction time. Benzodiazepines and TCAs were most commonly associated with impairment, although the level of impairment was dependent on the population studied, the dose and the time of testing relative to drug administration. Computer-simulated driving provides a useful tool to research psychotropic-related impairment of driving abilities. Limitations of currently available data include the lack of generalisability, standardisation and small sample sizes.     

Two contemporary cases of hepatitis associated with Teucrium chamaedrys L. decoction use: case reports and review of literature

Abstract: Teucrium chamaedrys L. is a herbaceous plant common in European woods that has been used for many purposes for centuries. Recently, T. chamaedrys L. has become popular as a slimming decoction without any scientific proof of efficacy notwithstanding its well‐known hepatotoxicity. Hydroalcoholic extracts are currently used as flavourings in the preparation of wines, bitters and liqueurs. Teucrin A and teuchamaedryn A are the major toxic components of the diterpenoid fraction of T. chamaedrys L.     

Testicular feminization syndrome. Four case reports with a brief review of the literature

Four cases of testicular feminization syndrome in Ethiopian patients are described. All four patients had normal female breasts, scanty pubic and axillary hair and absent internal genital organs. Three had bilateral inguinal or labial masses. The main features of their clinical presentation and histological studies are briefly discussed with a review of the literature.     

Priapism associated with atypical antipsychotic medications: a review

Priapism defined as persistent, painful and prolonged penile erection, was previously thought to be associated only with the use of the older, conventional first generation or typical antipsychotic medications as well as some other medications, notably, trazodone. The mechanism of priapism associated with antipsychotics is not clear but is thought to be related to alpha-adrenergic blockage that is mediated by the alpha receptors in the corpora cavernosa of the penis. Atypical antipsychotics, also known as second-generation antipsychotics, owing to their favorable side effect profile, are being prescribed with increasing frequency and are not as frequently considered to cause priapism. Some case reports reporting this side effect with their use, however, are found. Pubmed and Ovid databases were searched to obtain all articles and case reports of antipsychotic drug-induced priapism. Key search words included 'priapism', 'antipsychotics' and 'drug-induced priapism'. References of all identified studies were also reviewed. A total of 50 publications were obtained. Most of the atypical antipsychotics have been reported to cause priapism. These cases have occurred in patients shortly after having been started on the antipsychotic medications as well as in those who have been on them for an extended period of time without modification in dosage, and have also occurred sometimes, with the addition of another antipsychotic, lithium or serotonin-specific reuptake inhibitor. Priapism has been documented with nearly all the atypical antipsychotic medications. It is, however, a rarely reported side effect and therefore, underappreciated. Priapism can cause irreversible erectile dysfunction and is a urologic emergency. Clinicians should monitor patients on these medications for this rare, yet significant side effect. Furthermore, caution must be used when adding new drugs to the regimen and patients should be closely monitored for this side effect. Educating patients about the risk of developing priapism would help increase awareness of the side effect and promote early reporting thereby, decreasing long-term morbidity.     

Colchicine myotoxicity: case reports and literature review

Two of our patients experienced myotoxicity associated with colchicine administration. The first was a 54-year-old woman who was receiving dialysis and came to the emergency department with progressive generalized weakness and vomiting. She recently had taken colchicine for the treatment of gout. Physical examination revealed proximal muscle weakness and tenderness on palpation. Her creatine kinase (CK), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were elevated at 7185, 563, and 541 U/L, respectively. Drug-induced myopathy was suspected and colchicine was discontinued. The patient was discharged after symptom resolution 1 week later. The second patient was an 83-year-old woman with chronic renal insufficiency who came to the hospital with anorexia, diarrhea, and inability to get out of bed due to progressive weakness. Her colchicine dosage recently had been increased for gout management. Physical examination revealed generalized muscle weakness and tenderness on palpation. Her CK, ALT, and AST levels were elevated at 1797, 147, and 172 U/L, respectively. Electromyographic results were consistent with colchicine myopathy. The patient was discharged with minimal residual muscle weakness 1 week after discontinuation of colchicine. A literature search identified 82 documented cases of colchicine-induced myotoxicity. Most patients had a history of proximal weakness and pain with elevated CK, ALT, and AST levels. Onset of symptoms generally occurred days to weeks after initial administration of colchicine at the usual dosage in patients with renal impairment or a change in underlying disease state in those receiving long-term therapy. Muscle toxicity was not necessarily accompanied by gastrointestinal symptoms. Concomitantly administered drugs often were cyclosporine or corticosteroids. Diagnosis may be confirmed by electromyography or muscle biopsy. Colchicine-induced myotoxicity is a rare adverse effect but is well described in the literature. Clinicians should recognize that renal impairment is the primary risk factor for development of colchicine-induced myotoxicity, and that dosage adjustment or alternative therapy may be required.     

Antimicrobial-induced mania (antibiomania): a review of spontaneous reports.

The authors reviewed reported cases of antibiotic-induced manic episodes by means of a MEDLINE and PsychLit search for reports of antibiotic-induced mania. Unpublished reports were requested from the World Health Organization (WHO) and the Food and Drug Administration (FDA). Twenty-one reports of antimicrobial-induced mania were found in the literature. There were 6 cases implicating clarithromycin, 13 implicating isoniazid, and 1 case each implicating erythromycin and amoxicillin. The WHO reported 82 cases. Of these, clarithromycin was implicated in 23 (27.6%) cases, ciprofloxacin in 12 (14.4%) cases, and ofloxacin in 10 (12%) cases. Cotrimoxazole, metronidazole, and erythromycin were involved in 15 reported manic episodes. Cases reported by the FDA showed clarithromycin and ciprofloxacin to be the most frequently associated with the development of mania. Statistical analysis of the data would not have demonstrated a significant statistical correlative risk and was therefore not undertaken. Patients have an increased risk of developing mania while being treated with antimicrobials. Although this is not a statistically significant risk, physicians must be aware of the effect and reversibility. Further research clearly is required to determine the incidence of antimicrobial-induced mania, the relative risk factors of developing an antimicrobial-induced manic episode among various demographic populations, and the incidence of patients who continue to have persistent affective disorders once the initial episode, which occurs while the patient is taking antibiotics, subsides. The authors elected to name this syndrome "antibiomania."     

双膦酸盐相关性颌骨坏死1例并文献分析

1例62岁男性患者,因"右上颌拔牙后肿痛3个月余"入院,既往转移性前列腺癌并骨转移,2015年起规律使用唑来膦酸注射液,2018年11月拔除右上第一、二、三磨牙,拔牙窝创口未愈、肿胀、溃烂、溢液、触痛明显。2019年3月入院病理诊断为双膦酸盐相关性骨髓炎,行手术治疗和药物治疗,病情稳定后出院。双膦酸盐是有效的骨吸收抑制剂,能减少骨转移相关不良事件,双膦酸盐相关性颌骨坏死虽然罕见,但一旦发生将严重影响患者生活质量应引起足够重视。本文报道双膦酸盐相关性颌骨坏死1例,并复习相关文献,总结发病机制、相关危险因素、治疗手段及预防措施,以期为临床药物使用监护提供参考。     

Chelonitoxism: new case reports in French Polynesia and review of the literature.

Eating the flesh of some marine turtles can cause a type of seafood poisoning called chelonitoxism. The purpose of this article is to report a new case of mass poisoning caused by consumption of sea turtle flesh in French Polynesia. The episode involved 19 members of the same family. Three persons required hospitalization after consuming two consecutive meals including turtle flesh. One 26-year-old woman who was pregnant at 14 weeks of amenorrhea lapsed into a coma and died due to multiorgan failure on the third day after the meal. This case confirms the potential severity of chelonitoxism as reported in several series in the literature showing high mortality rates. The causative toxins are currently unidentified. Further study is needed to better understand chelonitoxism.     

NTRK重排宫颈肉瘤的病例报告及文献复习

本研究报道了2例年轻女性NTRK重排宫颈肉瘤的病例,通过分析患者的术前临床表现、影像学检查、结合宫颈肿块切除的病理诊断确诊。2例患者均采用手术治疗切除子宫,总体疾病无进展生存时间分别为20个月和11个月。本文通过复习近年来国内外相关报道,总结NTRK重排宫颈肉瘤的最新治疗进展。     

Pneumatosis cystoides intestinalis: case reports and review of the literature

Pneumatosis cystoides intestinalis is an uncommon condition in which submucosal or subserosal gas cysts are found in the wall of the small or large bowel. Many different causes of pneumatosis cystoides intestinalis have been proposed, including mechanical and bacterial causes. Approximately 85% of cases are thought to be secondary to coexisting disorders of the gastrointestinal tract or the respiratory system. Since 1986 we have observed 4 cases of pneumatosis cystoides intestinalis. A review of the literature is presented with emphasis on the etiology, diagnosis, differential diagnosis, and therapy of pneumatosis cystoides intestinalis. Symptoms of pneumatosis cystoides intestinalis include diarrhea, constipation, rectal bleeding, passage of mucus per rectum, vague abdominal discomfort, abdominal pain, urgency, malabsorption, weight loss, and excessive flatus. Depending on the location of the gas filled cysts the range of symptoms in each patient may vary enormously.     

Childhood longitudinal melanonychia: case reports and review of the literature

"Longitudinal melanonychia" refers to a brown or brown-black longitudinal band on a fingernail or toenail. A number of conditions can cause longitudinal melanonychia, but its main importance is that, in some patients, it may indicate the presence of a subungual malignant melanoma. Hyperpigmented nail bands are not uncommon in African-American, Latino and Asian patients, especially those over sixty years of age, and are often multiple in these groups. Longitudinal melanonychia is most worrisome when there is a solitary, dark, broad longitudinal band with pigment extending over the proximal nail fold (Hutchinson's sign). Such findings are considered to be a strong indication for biopsy of the nail matrix to rule out melanoma. Since nail matrix biopsy sometimes results in permanent nail deformity, and since the incidence of malignant melanoma is quite small in the pediatric age group, there is some controversy as to whether this procedure should routinely be performed in children. We report two cases of dramatic longitudinal melanonychia in toddlers and review the current literature on the management of this striking condition in the pediatric age group.     

Cleistanthus collinus poisoning: case reports and review of the literature

We report the cases of two previously healthy young patients who ingested the liquid extracted from the crushed leaves of Cleistanthus collinus (Family: Euphorbiaceae) in an attempt to commit suicide. Both patients developed life threatening complications such as hypokalemia, hypotension, cardiac arrhythmias, neuromuscular weakness, respiratory failure, and renal failure following a transient quiescent period of up to 4 days. Other significant findings noted include leucocytosis, coagulopathy, elevated liver enzymes, hyperchloremic metabolic acidosis, and an alkaline urinary pH. Both patients received supportive care as no specific antidote was available, and ultimately died. We have reviewed the published literature on C. collinus poisoning.     

Cardiovascular risk associated with testosterone-boosting medications: a systematic review and meta-analysis

Introduction: Recent reports have significantly halted the enthusiasm regarding androgen-boosting; suggesting that testosterone supplementation (TS) increases cardiovascular (CV) events.

Areas covered: In order to overcome some of the limitations of the current evidence, the authors performed an updated systematic review and meta-analysis of all placebo-controlled randomized clinical trials (RCTs) on the effect of TS on CV-related problems. Out of 2747 retrieved articles, 75 were analyzed, including 3016 and 2448 patients in TS and placebo groups, respectively, and a mean duration of 34 weeks. Our analyses, performed on the largest number of studies collected so far, indicate that TS is not related to any increase in CV risk, even when composite or single adverse events were considered. In RCTs performed in subjects with metabolic derangements a protective effect of TS on CV risk was observed.

Expert opinion: The present systematic review and meta-analysis does not support a causal role between TS and adverse CV events. Our results are in agreement with a large body of literature from the last 20 years supporting TS of hypogonadal men as a valuable strategy in improving a patient’s metabolic profile, reducing body fat and increasing lean muscle mass, which would ultimately reduce the risk of heart disease.