Quetiapine Therapy for Corticosteroid-Induced Mania

Abstract

Dear Editor: Corticosteroids are routinely used for immunosuppression in patients who have received liver transplants (1). Mood symptoms and psychosis have long been documented as potential adverse effects of corticosteroid treatment (2). We report a case of corticosteroid-induced mania that followed a liver transplant and that resolved with quetiapine therapy. A white man, aged 52 years, was admitted for a liver transplant. The donor was his biological brother. Approximately 5 years previously, he had been diagnosed with hepatitis B and hepatitis C. He had no psychiatric history; however, his daughter had been diagnosed with bipolar disorder. After the transplant, the patient was given methylprednisolone 50 mg intravenously every 6 hours (4 doses) and then 40 mg intravenously for an additional 4 doses. Cumulatively, he received more than 250 mg of steroids before the onset of behavioural symptoms. On postoperative day 3, psychiatry was consulted because he was talking incessantly, preoccupied with hyperreligious themes, and making hypersexual comments. He claimed that he was a prophet and that he could speak different languages; his speech contained numerous neologisms. He was grandiose and claimed to posses spiritual powers that enabled him to sense different pleasant odours. He refused to divulge his name for security reasons. He had not slept for the last 2 days. He was not physically aggressive or agitated. The Young Mania Rating Scale (YMRS, 3) was used to assess symptom severity; his total score was 31, indicative of mania. On a mental status examination, he was poorly groomed and disrobed repeatedly, but he was awake, alert, cooperative, and oriented as to place, person, and time. He displayed pressure of speech and rambling speech with incoherent narration, neologisms, and loose associations. His mood was significantly elevated and euphoric. His thought content revealed grandiose delusions, ideas of reference, and hyperreligious themes. His attention, concentration, insight, and judgment were poor. The presumptive diagnosis was steroidinduced mania. A CT scan of the head on postoperative day 3 was unremarkable. He had a benign neurological examination; there was no evidence of infection; and laboratory values were within normal limits. The patient was started on quetiapine 25 mg at bedtime and 12.5 mg as needed twice daily. Within 10 hours of quetiapine therapy, his mental status gradually improved. His YMRS score was less than 5 at discharge. His thought process and concentration improved significantly. …