Methylphenidate-induced priapism in a prepubertal boy.

Abstract

Byline: Nidhi. Chauhan, Sandeep. Grover, Vandana. Patidar Sir, Methylphenidate is a stimulant medication approved for pharmacological management of attention-deficit hyperactivity disorder (ADHD) in children above 6 years of age. Common side effects of methylphenidate use include insomnia, decreased appetite, weight loss, irritability, and anxiety. Tachycardia and hypertension have also been reported which may be dose related. One of the uncommon side effects of methylphenidate use includes priapism, which is understood as a prolonged full or partial penile erection which is unrelated to sexual stimulus.[sup][1] Following the publication of around 15 case reports of priapism in children (mean age - 12.5 years) associated with the use of stimulants, the US Food and Drug Administration issued a warning in 2013, suggesting an association between priapism and stimulants (methylphenidate and atomoxetine).[sup][2] Most of the cases of priapism seen with the use of methylphenidate have been observed in children aged 8 years or more and adolescents. In this report, we present a case of a 4-year-old male who presented with the symptoms of priapism and review the literature on the association of methylphenidate and priapism. A 4-year-old boy was brought with the chief complaints of rubbing his penis repeatedly after started using methylphenidate. Detailed evaluation of his history revealed that he was born out of a wanted, planned pregnancy of nonconsanguineous marriage by in vitro fertilization. He was delivered by an elective cesarean section, without any antenatal or perinatal complication. He cried immediately after birth, his birth weight was ~ 2.2 kg, and breastfeeding was instituted immediately after birth. He developed transient physiological jaundice which resolved in 2–3 days without any phototherapy. He had delayed development of milestones in all domains of fine motor, gross motor, speech, language, and communication. He started walking by the age of 21/2 years. By 3 years of age, when he was sent to play school, he was noticed to be restless, would not sit still even for 5 min, would be always on the go, keep fiddling with objects in his reach, playing with them for few minutes, and then throwing them away. At the play school too, he would not sit on his seat, instead kept on roaming in the entire class, disturb other children, despite repeated instructions of teachers to not to do so. If made to sit forcibly, he would keep on moving his limbs and appear restless. He would not pay attention to what was being taught in class, instead keep on looking outside the windows and doors. When teachers would try to engage him in any activity such as drawing, he would finish it fast and then interrupt other children in their work. He had difficulty in waiting for his turn while playing; often insist to let him play first. He would keep talking something or the other or singing a rhyme despite being told not to do so. He often interrupted others during conversations. In addition, he often lost his belongings at school. As a result, he was not able to learn and lagged behind his peers. Parents thought that things would improve as he grew but all these behaviors kept on increasing. Due to his behavioral problems, there were frequent complaints from the school and this led to a psychiatric consultation. He was evaluated by a psychiatrist, was diagnosed with ADHD, and was started on tablet methylphenidate (immediate release) 5 mg/day in the morning. Over the period of the next 2–3 months, there was about 50% reduction in his hyperactivity. However, after about 3 months of continuing methylphenidate, the family members observed him to be rubbing his penis repeatedly, many times a day, each time for 5–10 min, especially few minutes to half an hour after being administered the morning dose of methylphenidate. When family members would ask him to stop, he would not stop and it would appear that he was unable to control it. …