Ofloxacin Induced Hypomania

Flouroquinolones are widely used antibiotics with side effects that involve the central nervous system. Here, we are presenting the case of a patient who developed hypomania after taking ofloxacin. The clinical features included an elevated mood, increased talkativeness, a decreased need for sleep, and drawing up big plans. The episode was circumscribed and resolved after the discontinuation of the antibiotic.

Mr. M, a 47 years married male who works as an accountant, came with a request for an evaluation for the continuation of his medication. The patient had developed moderate grade fever with cough and he had also developed a difficulty in breathing. He went to the physician within 2 days of having the fever. The records show that he had crepitations on the left side of the chest. He had been prescribed antipyretics (paracetamol and ibuprofen combination) and ofloxacin. He took these medications for 5 days and responded favourably. There was improvement in his fever and expectoration. After starting the medication, in two day’s time, he reported a decreased need for sleep. He would stay awake all night and seemed to be full of energy in front of his family members. He seemed to be more talkative, according to his wife. He would talk mainly about his job, and the measures he would suggest for his company’s benefit. He drew up specific plans for doing his job in an efficient manner. He would feel cheerful and would be more optimistic than his usual self. He stayed at home during this time and there was no history of any disinhibited behaviour, restlessness, grandiosity, distractibility or hallucinations. A colleague who visited him during that time, suggested to him to take the help of a psychiatrist. The patient was then taken to a physician within 5 days of the start of the fever and he was started on clonzepam 1.5 mg in divided doses, and olanzapine 7.5 mg. His sleep and talkativeness improved. He discontinued all the medications in 2 weeks and did not experience any symptoms thereafter. Thereafter, he presented to our OPD for a second opinion. The patient did not have any past history of depressive, hypomanic or manic episodes, or any other psychiatric history. There was no family history of any psychiatric illness. There was no history of any psychoactive substance use except of smoking 1 to 2 cigarettes in a day. The premorbid personality revealed some anankastic traits. He has been doing well for more than a year after the discrete episode of the elevated mood and the sleeplessness of around 7 days. Given the history, medication induced hypomanic episode was the most likely possibility.

In this patient with no family history of bipolar illness, the first episode of the illness occurring in the fifth decade and the temporal association of the symptoms with the use of medications, suggested that the medications should be incriminated as the cause of the hypomanic episode. Also, the episode had been fairly circumscribed, lasting approximately a week and the symptoms responded to cessation of the medication and the start of antipsychotics in lower doses.

Among the medications whioch were administered for the resolution of the chest infection in this patient, ofloxacin seems to be the likely culprit for the manic symptoms. Antitussives have not been described to cause manic or hypomanic symptoms, neither have been the antipyretic agents. The flouroquinolones which includ ofloxacin, are one of the quite widely used antibiotics in the medical field and the prominent side effects of these medications include those of the gastrointestinal and the central nervous system [1]. There are few case reports on fluoroquinolones causing manic [2–4] and psychotic symptoms [5,6]. Hence, in the present case, ofloxacin seems to be the most likely cause of the hypomanic symptoms.

Hypomania has been described in ICD 10, as a disorder which is characterized by a persistent mild elevation of the mood, increased energy and activity, and usually marked feelings of well – being and both physical and mental efficiency. Mania is described as a condition of an elated mood with pressured speech and increased activity, with distractibility. The present case with a history of minimal dysfunction was suggestive of hypomania.

This case highlights the need for a close observation of the patients who receive fluoroquinolones for the emergence of the psychiatric symptoms. Careful consideration should be made about whether the symptoms, if they are present, are due to the institution of antibiotics, or whether there are independent of other risk factors.

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