Mania secondary to cotrimoxazole antibiotherapy: a case report and review of literature

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BackgroundAntibiomania is the manifestation of manic symptoms secondary to taking an antibiotic, which is a rare side effect. In these cases, the antibiotics most often incriminated are macrolides and quinolones, but to our knowledge, there are no published cases of antibiomania secondary to cotrimoxazole. Furthermore, we also provide an update of pharmacovigilance data concerning antibiomania through a search of the World Health Organization (WHO) database.Case presentationWe present the case of a 66-year-old Caucasian man with history of a brief psychotic episode 16 years prior. He received levofloxacin for a urinary infection with Klebsiella pneumoniae, with a switch to cotrimoxazole after 5 days of treatment. Shortly after the introduction of cotrimoxazole, the patient presented with a significant flow of speech, which was incoherent. After 2 days of treatment, levofloxacin was restarted, but given the lack of improvement in symptoms, the patient was hospitalized. Levofloxacin was quickly replaced by ceftriaxone for 3 days without improvement, thus a psychiatric examination was requested. This examination identified manic symptoms, and so psychotropic treatment combining 5 mg of haloperidol and 75 mg of loxapine per day was initiated. Subsequently, there was a gradual improvement in symptoms within a week. Moreover, the results of the various investigations that were carried out came back normal, which this led to suspicion of an iatrogenic cause (antibiotherapy).DiscussionWe discuss the latest pharmacovigilance data and several etiopathogenic hypotheses suggested in literature, with growing interest concerning the microbiota–gut–brain axis. It appears important to pay particular attention when taking antibiotics in the context of bipolar disorder because this association seems to precipitate the appearance of secondary mania. Management consists of stopping the responsible antibiotic, with the possibility of adding psychotropic treatment.ConclusionIt is important to be aware of antibiomania to adopt appropriate and early treatment. We think that this case report could be useful as a clinical reminder and could possibly spark lines of research.