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Secondary Mania Induced by Antituberculous Medications

Yu-Yu Tsai, Chia-Hao Liang, Bo-Chung Chu, Te-Jen Lai

A 58-year-old male patient was previously
healthy, without personal or family history of psychiatric
disorder. Three months before admission
to our acute psychiatric ward, he presented himself
with a 10-day high fever, headache, photophobia,
and conscious disturbance. Neurological
examination revealed signs of meningeal irritation
(neck rigidity and Kernig’s sign). The result of cerebrospinal
fl uid culture showed positive for nontuberculous
mycobacteria (NTM).

To treat the NTM meningitis, the patient received
daily doses of antituberculous medications
with isoniazid 300 mg, rifampin 600 mg and ethambutol
800 mg. His fever subsided, and the
physical conditions were improved after a onemonth
treatment course. Then, a one year course
of treatment with antituberculous medications
was suggested without adjusting drug or dosage.

In month 2 of the antituberculous treatment,
the patient gradually developed manic symptoms
including elevated mood, irritability, hyperactivity,
grandiosity, decreased need for sleep, talkativeness,
fl ight of ideas, increased goal-directed
activity, increased buying sprees, and several
risky behaviors such as climbing a roof and drag
racing. He was hence admitted to our ward. His
laboratory tests and brain computed tomography
showed no specifi c abnormality. The result of
electroencephalography revealed normal awake
tracing.

To treat the acute manic episode, the patient
received quetiapine 150 mg per night. He continued
the antituberculous medications at a physician’s
suggestion. On day 5, we changed the antipsychotics
to olanzapine and added valproate for
his persistent manic symptoms. His valproate
dose was gradually increased to 1,500 mg per day
on day 19. The olanzapine dose was increased to
20 mg per night on day 14. He exhibited fewer
manic symptoms subsequently, and was discharged
on day 29.

After discharge, the patient’s psychotropic
drugs doses were gradually titrated. He took only
500 mg of valproate per night since 4th month after
discharge and discontinued the antituberculous
and psychotropic drugs since 10th month. He exhibited
a continuously stable mood after a 1.5-
year follow-up. We suggest that the manic episode
was related to the use of the antituberculous
medications.
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Editorial Committe, Taiwanese Journal of Psychiatry
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