Body dysmorphic disorder due to hirsutism in a patient treated with cyclosporin

Abstract

Sir, Currently administered immunosuppression schemes usually include cyclosporin. Cyclosporin has brought about a revolution in patient prognosis and in renal graft survival, but, unfortunately, it has many side effects [1,2]. While physicians are attentive to the more serious and life threatening of these side effects, there are others which, although not life threatening, can compromise the patient’s quality of life. To the latter group belongs hirsutism. The incidence of cyclosporin-induced hirsutism in renal graft recipients is 5% [1,2]. We describe the case of a 20-year-old male patient with end-stage renal disease due to Alport’s syndrome. After 5 months on haemodialysis, the patient received a renal transplant from his father. On discharge from the hospital, the patient was taking Medrol 56mg/day, mycophenolate mofetil 1.5 g/day and cyclosporin A 400mg/day. Over a 3 month period, he developed heavy hirsutism of the face and body, which affected both his mood and his social behaviour. He withdrew from his daily activities, became socially isolated and declared that he would stay at home and stop his education. At that time, his serum creatinine was 1.1mg/dl. The patient was referred to a psychiatrist and the final diagnosis was body dysmorphic disorder [3]. It must be noted that in our department, a psychiatric examination is obligatory for any transplant candidate. In this case, the examination was done a few months before transplantation and showed no psychiatric disorder. Because of this, and despite the good graft function, cyclosporin was switched to tacrolimus (10mg/day), an efficient immunosupressive drug that dose not cause hirsutism [1,2,4]. The hirsutism disappeared gradually, and both the mood and behaviour of the patient were restored. One year later, the patient’s serum creatinine is 1.2mg/dl and the dose of tacrolimus is 5mg/day. Although hirsutism occasionally leads to patient noncompliance, our patient was compliant with medications, but he also fulfilled the criteria oulined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) of the American Psychiatric Association for body dysmorphic disorder [3]. These criteria are: (i) preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person’s concern is markedly excessive; (ii) the preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning; and (iii) the preoccupation is not better accounted for by another mental disorder. Body dysmorphic disorder is a serious situation that needs psychiatric evaluation as it is often accompanied by major depression; suicide attempts are rather common [5]. In conclusion, physicians should take care, not only of directly life-threatening side effects of an immunosuppressive regimen, but also of other side effects that can compromise the patient’s quality of life. In this case, the switch from cyclosporin to tacrolimus was enough to restore the patient’s physical and mental status.