Trimethoprim-Sulfamethoxazole–Induced Psychosis Culminating in Catastrophic Self-Injury

Parashar, Sunil; Roy, Nikita; Osuagwu, Ferdnand C; Khalid, Zaira; Tinklepaugh, Mary; Mehr, Shahzad; Dillon, James E.

doi:10.4088/pcc.15l01828

Cited by 4 publications

(3 citation statements)

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“…[ 10 12 13 ] Three cases have been reported in healthy adults’ ages 18, 19, and 46 with no psychiatric history who developed visual and auditory hallucinations in response to TMP-SMX, leading one of them to shoot himself in the face. [ 1 3 14 ] Two of them were taking oral double-strength tablets (160 mg TMP/800 mg SMX) BID, whereas the patient described in this case took half that dose and still developed CNS side effects. Given these historical reports of TMP-SMX-induced psychosis in nonelderly immunocompetent patients, there is an increased likelihood that the woman in this case developed hallucinations secondary to TMP-SMX.…”

Section: Discussionmentioning

confidence: 98%

“…In a study consisting of 1121 hospitalized patients, serious drug toxicity was rare and no episodes of delirium were reported. [ 4 ] The mechanism of action of TMP-SMX-induced psychosis and central nervous system (CNS) toxicity is not definitively known, but biochemical pathways have been implicated,[ 3 ] and it is known that it has excellent cerebrospinal fluid penetration. [ 5 6 ] TMP is also an irreversible dihydrofolate reductase inhibitor and thus reduces the conversion of dihydrofolate to tetrahydrofolate, the active form of folic acid that is essential in the formation of deoxythymidine monophosphate for DNA synthesis.…”

Section: Discussionmentioning

confidence: 99%

“…It is important for physicians to be aware of the drug's neurological adverse effects, which consist not only of hallucinations but also of delusions, depression, agitation, confusion, and suicide attempts because resolution requires immediate discontinuation of the medication. [ 2 3 ] This paper presents a unique case of a middle-aged immunocompetent patient who developed visual and tactile hallucinations after treatment with oral TMP-SMX for preseptal cellulitis, also known as periorbital cellulitis.…”

Section: Introductionmentioning

confidence: 99%

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Psychosis resulting from trimethoprim-sulfamethoxazole treatment for preseptal cellulitis

Iqbal

Luke²,

Ingram³

2022

Taiwan J Ophthalmol

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Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly used antimicrobial agent because of its low cost, diverse antimicrobial profile, and minimal severe adverse effects. A rare side effect is psychosis, a complication that has not been published in the ophthalmology literature. A 53-year-old female presented to the ophthalmology office with left upper eyelid erythema, focal tenderness, and discharge. She was diagnosed with preseptal cellulitis of the left upper lid and started on TMP-SMX. The next day, the patient's condition improved with reduced swelling and no discharge. However, 2 days later, she experienced visual hallucinations whereby worms were growing out of her left eye accompanied by theme-congruent tactile hallucinations. TMP-SMX was discontinued and substituted for clindamycin, and she reported resolution of her symptoms 8 h later. TMP-SMX has extensive cerebrospinal fluid penetration and causes a folic acid deficiency, which may explain the rare occurrence of neuropsychiatric side effects. This patient had a substance-induced psychosis, in which visual and tactile hallucinations began 3 days after taking TMP-SMX and resolved 8 h after discontinuation, a timeline consistent with the literature. Central nervous system toxicity is rare in nonelderly immunocompetent patients, with only three such cases reported in the literature. While visual and auditory hallucinations have been described previously, this is the first reported case of TMP-SMX-induced tactile hallucinations and unilateral visual hallucinations. Moreover, because TMP-SMX is a first-line agent commonly used to treat orbital and preseptal cellulitis, it is important for ophthalmologists to be aware of this atypical side effect, as it can be life threatening.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Psychosis resulting from trimethoprim-sulfamethoxazole treatment for preseptal cellulitis

Iqbal

Luke²,

Ingram³

2022

Taiwan J Ophthalmol

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From bacteria to fish: ecotoxicological insights into sulfamethoxazole and trimethoprim

Diogo,

Rodrigues,

Golovko

et al. 2024

Environ Sci Pollut Res

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Sulfamethoxazole (SMX) and trimethoprim (TRIM) are two of the most used antibiotics in the last 50 years, to prevent and treat bacterial infections; however, the available literature about toxicity to non-target organisms is quite discrepant and incomplete. This study aims to assess the SMX and TRIM ecotoxicological effects in standard species: Aliivibrio fischeri (bioluminescence inhibition), Escherichia coli ATCC 25922 (growth inhibition), Lemna minor (growth inhibition and biochemical biomarkers), Daphnia magna (immobilization/mortality, life history traits, and biochemical biomarkers), and Danio rerio (survival, hatching, abnormalities, and biochemical biomarkers). The species tested showed different acute sensitivities to SMX (A. fischeri < D. magna < E. coli < L. minor) and TRIM (L. minor < A. fischeri < D. magna < E. coli). Overall, TRIM reveals less toxicity than SMX, except for E. coli (Ecotoxicological approach based on Antimicrobial Susceptibility Testing – EcoAST procedure). Both antibiotics affect individually (e.g., growth and survival) and sub-individually (e.g., antioxidant defenses) L. minor, D. magna, and D. rerio. This study allowed us to generate relevant data and fill gaps in the literature regarding the effects of SMX and TRIM in aquatic organisms. The here-obtained results can be used to (i) complete and re-evaluate the Safety Data Sheet to improve the assessment of environmental safety and management of national and international entities; (ii) clarify the environmental risks of these antibiotics in aquatic ecosystems reinforcing the inclusion in the 4th Watch List of priority substances to be monitored in whole inland waters by the Water Framework Directive; and (iii) combat the development of antimicrobial resistance, as well as supporting the definition of environmental measurements in the context of European One Health Action Plan. However, it is essential to continue studying these antibiotics to better understand their toxicity at ecologically relevant concentrations and their long-term effects under different climatic change scenarios.

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Neurological and Psychiatric Adverse Effects of Antimicrobials

Bangert

Hasbun

2019

CNS Drugs

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Trimethoprim-Sulfamethoxazole–Induced Psychosis Culminating in Catastrophic Self-Injury

Cited by 4 publications

References 4 publications

Psychosis resulting from trimethoprim-sulfamethoxazole treatment for preseptal cellulitis

Psychosis resulting from trimethoprim-sulfamethoxazole treatment for preseptal cellulitis

From bacteria to fish: ecotoxicological insights into sulfamethoxazole and trimethoprim

Neurological and Psychiatric Adverse Effects of Antimicrobials

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