AGITATED SLEEPWALKING WITH FLUOROQUINOLONE THERAPY

Abstract

To The Editors: Modern fluoroquinolone antibiotics are rapidly bactericidal and exhibit a broad antimicrobial spectrum.1 Experience with fluoroquinolones in childhood has been limited because of their potential to induce arthropathy in young animals.1 Use of fluoroquinolones in children suffering from infections complicated by special conditions is currently justified when alternative safe treatment is not available.1 Sleep disorders are rare but recognized adverse events with fluoroquinolones.2 We report a 10-year-old girl with severe parasomnia complicating medication with ciprofloxacin. The child was referred because of recurrent urinary tract infections and involuntary loss of urine for several years. A diary recording urine output, the physical examination, ultrasonography, voiding cystourethrography and urodynamic studies disclosed signs of severe dysfunctional voiding including micturition occurring in several small fractions, incomplete bladder emptying and overactivity of the pelvic floor muscles during micturition.3, 4 Chemoprophylaxis with trimethoprimsulfamethoxazole, timed voiding and pelvic floor therapy did not ameliorate the tendency toward incontinence and recurrent infections. Furthermore uropathogens developed resistance to common antimicrobics such as trimethoprimsulfamethoxazole, nitrofurantoin, amoxicillin/clavulanic acid and oral third generation cephalosporins. Chemoprophylaxis with ciprofloxacin 60 mg daily at night (corresponding to 1.9 mg/kg body weight) was initiated. This medication corrected the incontinence and the urinary tract infections. Within a few days of instituting chemoprophylaxis with ciprofloxacin, episodic agitated sleepwalking lasting 5 to 10 min was noticed two to three times a week. Sleepwalking was associated with frequent bizarre motor activities that repeatedly led to minor self-injuries. Generally there was amnesia for the events. The child's sleep problems remained unreported on several visits for 4 months but resolved after withdrawing ciprofloxacin. Apart from the present case the use of ciprofloxacin has been linked with transient nightmares in two highly febrile children in the context of enteric fever.5 This pediatric case of severe and long lasting sleepwalking caused by a fluoroquinolone brings out two points. First, parents are too rarely questioned about the sleep characteristics of their children.6, 7 Second, given that sleepwalking is much more prevalent in children than in adults,6, 7 physicians are at risk to overlook the potential of fluoroquinolones to induce parasomnias.2 Rodo O. von Vigier, M.D. Silvano Vella, M.D. Mario G. Bianchetti, M.D. Departments of Pediatrics; Inselspital; Bern, Switzerland