Psychotic mania induced by the withdrawal of pegylated interferon and ribavirin treatment

Abstract

Mr R was a 45-year-old man who had been diagnosed with hepatitis C, genotype 3a. He was commenced on a 16-week course of pegylated interferon-α2a 180 μg per week and ribavirin 400 mg twice daily. He was otherwise healthy and had recently completed the Boston marathon. During treatment the only complaints Mr R made were of sleep disturbance and weight loss as a result of reduced appetite which are recognized side effects of the treatment. Six days after completion of his treatment Mr R was picked up in the street by the police following several complaints from members of public. He was seen trying to damage parked cars and shouting repeatedly that he was God. He was agitated and had to be handcuffed by the police who escorted him to hospital. A physical examination was unremarkable except for a raised pulse rate of 120 beats per minute. There was no significant abnormality in his blood test results. He was placed on Section 2 of the Mental Health Act for assessment of a suspected mental illness. Mr R had neither a past psychiatric history nor any past family psychiatric history. On admission to the psychiatric ward he believed that he was being followed on CCTV and made sexually inappropriate comments to staff. As he continued to be highly agitated olanzapine 10 mg intramuscularly was administered. Over the next day Mr R remained elated in mood and irritable with paranoid thoughts. Mr R did not require further emergency intramuscular medications as he gradually became calmer and more cooperative. Three days after admission his mental state and behaviour began to show significant improvement. He had wished not to take oral olanzapine that was prescribed and hence no psychotropic medications were used following the initial olanzapine dose on admission. Mr R said that he had no recollection of being brought in by the police or his psychotic behaviour. He and his family denied that alcohol or illicit drugs had been used. He did recall that his sleep had been very poor, a common feature in mania, in the days before his admission. A computed tomography scan of his head was normal. Seven days after admission he was visited by his family and allowed leave off the ward as there were no remaining psychotic or manic symptoms. He was later discharged from the ward after uneventful leave at home and remained well 6 months on.