Cases That Test Your Skills

After the ‘pink clouds,’ he sees red

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Mr. T receives lamotrigine for longstanding mood swings, hypomania, irritability, and anxiety. Two weeks later, a rash covers much of his body. Is the anticonvulsant to blame?


 

References

HISTORY: Depressed and sick

Mr. T, age 53, was diagnosed last year with hepatitis C and for 20 years has battled recurrent major depression with euthymia between episodes. His hepatologist asks us to evaluate his recent depressed mood and erratic behavior.

Less than 2 months ago, the hepatologist prescribed ribavirin, 1,000 mg bid, and peginterferon alfa-2B, 10 million IU/1.0 mL weekly, for hepatitis C. Soon afterward, Mr. T became irritable, especially toward his wife. He now refuses to leave his house most days because of overwhelming sadness and hopelessness. Once an avid motorcycle enthusiast, Mr. T has stopped riding and complains of fatigue, “fuzzy” thinking, and diminished concentration, but he denies suicidal thoughts or intent. He weighs 232 lb but has lost 15 lb in the last 6 weeks.

Five weeks ago, the hepatologist added bupropion XL, 150 mg/d, for Mr. T’s depressive symptoms, but the patient complained that the antidepressant “amped me up” and “made my mind race.” After 3 weeks, the hepatologist switched to escitalopram, 10 mg/d, but Mr. T’s agitation continued.

Several days after starting escitalopram, Mr. T experienced what he calls a “pink cloud” period—intensely pleasurable episodes that he says began in late childhood, usually last about 4 days, and occur 6 times annually. During these episodes, his thoughts race, his speech is mildly pressured, and he sleeps 5 hours or less nightly. While euphoric, he drives his motorcycle at 100 mph, starts several projects at once, and is distractible.

Once the “pink clouds” clear, Mr. T feels fatigued and “let down” as he does now. He says he has never reported these euphoric periods because he usually enjoys them.

Mr. T also has longstanding anxiety. Most days he is “on edge” and restless, feels muscle tension in his neck, and has trouble falling and staying sleep. After changing jobs last year, he began having panic attacks triggered by excessive worry. He denies anticipatory fear or avoidance, so we rule out panic disorder.

Additionally, Mr. T has been engaging in weekly binge-eating episodes during which he consumes nearly 50 large-sized cookies and 2 to 3 2-ounce bags of potato chips in 2 hours. He is wracked with guilt after bingeing and often feels embarrassed about being overweight (body mass index, 31 kg/m2). He does not purge but moderately restricts his diet between binges. He says he started bingeing at age 20, and at one point was bingeing 3 times a week.

Mr. T also complains that ribavirin and peginterferon are causing headaches, fatigue, and myalgias. He also takes hydrochlorothiazide, 25 mg/d, for hypertension, and is allergic to sulfonamides. He denies using alcohol and drugs but smokes 2 packs of cigarettes per day.

We diagnose bipolar II disorder based on Mr. T’s extreme mood shifts, history of major depressive episodes, recent hypomania, lack of manic or mixed episodes, and significant distress. His hypomania episodes last <1 week; episodes that last ≥1 week or require hospitalization would signal bipolar I disorder.

We rule out interferon-induced depression and hypomania1 because Mr. T showed signs of mood dysfunction long before he contracted hepatitis C. We also diagnose generalized anxiety disorder and eating disorder, not otherwise specified.

The authors’ observations

Diagnosing and managing bipolar disorder is challenging, especially when hypomania is not readily apparent.2

After we discuss treatment options with Mr. T, he chooses lamotrigine because it causes relatively few side effects and is less likely than valproic acid and other mood-stabilizing anticonvulsants to cause hepatotoxicity or pancreatitis.3 Lamotrigine also might reduce Mr. T’s anxiety.4

We do not try lithium because Mr. T is taking a diuretic (hydrochlorothiazide), which can cause lithium toxicity when used concomitantly. Also, lithium requires close laboratory monitoring, interacts with many medications, and can cause drowsiness, dry mouth, blurry vision, and fatigue.5 These
factors contraindicate lithium for Mr. T, who is taking several medications and suffers side effects from ribavirin and interferon.

Olanzapine might control Mr. T’s mood swings, but the neuroleptic can cause weight gain and metabolic syndrome6 and might complicate his eating disorder.

TREATMENT: A ‘rash’ reaction

We add lamotrigine, 25 mg/d, for 2 weeks and then increase to 50 mg/d.

Two days after the lamotrigine increase, Mr. T reports a rash on the left side of his trunk and left hip, buttock, and elbow (Figure). He also complains of mild chills and night sweats, although these symptoms emerged several weeks ago. He denies blistering, fevers, dysuria, nausea, or vomiting. We see no signs of lymphadenopathy, and mucosae are unaffected. Since he started lamotrigine, he says, he has not tried unfamiliar brands of shampoos, laundry detergents, or shower gels that might irritate his skin.

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