Psychotic Mania Associated with Mefloquine in a Bipolar Patient

Abstract

A 63-year-old male patient with a history of bipolar I disorder presented to the emergency department in an acutely psychotic state. The patient had just returned from vacation in a malarial high-risk area and, as a result, had taken five weekly doses of mefloquine for prophylaxis. The patient's bipolar disorder was being treated with lithium, and he had been stable for about 8 years. All organic causes of psychosis were ruled out. The patient was admitted to the inpatient psychiatric unit and was treated with quetiapine until he was stable enough to return home.

Experimental Confirmation of New Drug–Target Interactions Predicted by Drug Profile Matching

“…We measured strong antagonistic effects of mefloquine on D1 and D2 (82% and 90%, respectively), while only a moderate agonistic effect was observed on the D2 receptor (45%) and no agonist effect was detected on the D1 receptor. Antimalarial drugs like mefloquine are known to induce psychosis. , The underlying mechanism is unknown; however, it is hypothesized that several neurotransmitter systems might be involved, including the dopaminergic system which would be in agreement with our findings …”

“…Antimalarial drugs like mefloquine are known to induce psychosis. 64,65 The underlying mechanism is unknown; however, it is hypothesized that several neurotransmitter systems might be involved, including the dopaminergic system which would be in agreement with our findings. 66 The selective estrogen receptor modulator raloxifene produced strong antagonistic effect on both dopamine receptor subtypes (of 97% and 88% on the D1 and D2 receptors, respectively), and the effect of steroids possessing estrogen-like activity on the dopamine system has been widely discussed in the literature.…”

Quinacrine induced mood disturbance - the unmasking of bipolar affective disorder

“…A Dutch case control study found a threefold increase in the incidence of psychiatric events with mefloquine use in over 500 travelers16 and a literature survey found that mefloquine use was causally associated with three suicides 17. Mefloquine has been demonstrated to have an association with episodes of manic relapse in individuals with a history of bipolar disorder18 and has been associated in one case series with six episodes of acute psychosis 19…”

Prolonged Neuropsychiatric Symptoms in a Military Service Member Exposed to Mefloquine

“…Neuropsychiatric side effects attributed to mefloquine use range from common mild symptoms of insomnia, anxiety, mood changes, headaches, dizziness or vertigo to more severe and rare psychoses, violent behaviors, seizures, neuropathies and even suicide. Case reports describe a wide range of these and other symptoms, including symptoms of bipolar disorder, peripheral polyneuropathy, paranoid psychosis and suicide [7–11]. Rates of neuropsychiatric symptoms from prospective studies have ranged anywhere from 8 to 77 % [12–15].…”