Abstract
To the Editors:
A
The prevalence of bipolar disorder (BPD) in subjects with ASD has not been clearly established; however, a recent review has revealed that a significant minority (7%) suffer from BPD (Skokauskas and Frodl 2015). Munesue et al. (2008) have shown that 16 out of 44 consecutive outpatients with high-functioning ASD were diagnosed with mood disorders, and diagnosis of BPD was more frequent than major depressive disorder. It was suggested that ASD may share common genetic underpinnings with BP (Carroll and Owen 2009).
Herein we report a child with ASD who developed mania during oral decongestant administration.
Case
A 10-year-old boy with diagnosis of ASD and mild intellectual disability was admitted to our outpatient clinic by his father with complaints of insomnia (4–5 hours per night), decreased appetite, agitation, increased motor activity, worsening of irritability, self-injury behaviors, and hypersexuality (e.g., rubbing his genitalia frequently). According to his father's report, these symptoms were evident for 5 days, after starting an oral decongestant (Tylol-Cold Suspension) for his flu-like symptoms by his pediatrist. His father reported that he started to exhibit these behaviors 2 hours after receiving the medication.
He was diagnosed with ASD when he was 4 years old and since that time he was receiving specialized education. He was on risperidone 1.25 mg/day for 4 months, receiving for his irritability, aggression, and hyperactivity. In his family history, son of his aunt had a diagnosis of BPD, and his four cousins were diagnosed with ASD.
According to the clinical picture and history of the subject, we gave a diagnosis of drug-induced mania and ceased the oral decongestant. One week later, in his second visit, his father reported that his behaviors resolved within 4 days.
Discussion
Development of mania during oral decongestant use and disappearance after cessation may suggest causality. Naranjo causality scale (Naranjo et al. 1981) revealed a score of 7, indicating a probable adverse drug reaction. To our knowledge, this is the first reported case of a child with ASD who developed mania with oral decongestant.
In the literature, there are several reports describing association between decongestants and mania in subjects with BPD and with a family history of BPD (Wood 1994; Bostwick 1996; Polles and Griffith 1996). It was suggested that underlying BPD may be considered as risk for developing mania with decongestants. The reported case had irritability, aggression, and hyperactivity in his personal history that might be symptoms of subsyndromal BPD and his family history was positive for BPD.
The oral decongestant used in the current report included paracetamol (160 mg), pseudoephedrine hydrochloride (15 mg), dextromethorphan (5 mg), and chlorpheniramine (1 mg). There are reports describing mania associated with paracetamol (Orr et al. 1998), pseudoephedrine (Wilson and Woods 2002), and dextromethorphan (Polles and Griffith 1996). Prostaglandin reduces the level of dopamine and paracetamol inhibits prostaglandin synthesis, which might be a possible explanation for mania associated with paracetamol (Hergüner and Özayhan 2015). Pseudoephedrine has a sympathomimetic effect and may induce mania through stimulating the noradrenergic system. Dextromethorphan has antagonism at N-methyl-
This case highlights the fact that decongestants may cause manic symptoms. Clinicians should be alert to this possibility in subjects with a personal and/or family history of BPD.
Footnotes
Disclosures
The authors do not have any actual or potential conflict of interest, including any financial, personal, or other relationships with other people or organizations that could inappropriately influence or be perceived to influence.