|Year : 2019 | Volume
| Issue : 4 | Page : 247-249
An unusual occurrence of deriphyllin-induced hallucinations: Contingency of concern
Mohit Dahiya1, Nehal R Parikh2, Deepak S Malhotra3, Shikha V Sood2
1 Department of Surgery, Apollo Hospital, Bhat, Ahmedabad, Gujarat, India
2 Department of Pharmacology, Smt. NHL Medical College, Ahmedabad, Gujarat, India
3 Department of Neurosurgery, Apollo Hospital, Bhat, Ahmedabad, Gujarat, India
|Date of Submission||29-Aug-2019|
|Date of Acceptance||11-Nov-2019|
|Date of Web Publication||12-Dec-2019|
Deepak S Malhotra
Department of Pharmacology, Smt. NHL MMC, Ellis-Bridge, Ahmedabad - 380 006, Gujarat
Source of Support: None, Conflict of Interest: None
Deriphyllin has been a mainstay of asthma therapy despite its narrow therapeutic index and a large pharmacokinetic variability between patients. Here, the authors decided to report a rare case of suspected deriphyllin-induced hallucinations in adults for the first time. An 83-year-old male patient who was a known case of recent onset asthma was on tablet deriphyllin 150 mg BD and salbutamol nebulization BD. He underwent emergency drainage of subdural hematoma due to a history of fall 20 days back with head injury. Within 2 days, he improved and was discharged 3 days later with the medicines. On follow-up after 7 days, he was admitted with a chief complaint of hallucinations. After stopping tablet deriphyllin, the patient's condition drastically improved in next few days and neurology was completely normal. Drug dechallenge was positive in this case since the hallucinations subsided after discontinuation of suspected drug deriphyllin. There are no such cases published previously.
Keywords: Deriphyllin, drug dechallenge, elderly, visual hallucinations
|How to cite this article:|
Dahiya M, Parikh NR, Malhotra DS, Sood SV. An unusual occurrence of deriphyllin-induced hallucinations: Contingency of concern. Apollo Med 2019;16:247-9
| Introduction|| |
Deriphyllin is a combination of etophylline and theophylline (1,3-dimethylxanthine) from methylxanthine group. These are extensively prescribed in developing countries like ours because it is inexpensive. It is a nonselective phosphodiesterase inhibitor, an effect that could simulate beta receptor stimulation by increasing intracellular levels of cyclic-AMP. It can indirectly stimulate both β1 and β2 receptors through release of endogenous catecholamines. Theophylline has narrow therapeutic index and a large pharmacokinetic variability between patients which makes toxicity a common problem. Adverse effects may be evident within the normal therapeutic range. Drug-induced hallucination is a relatively common symptom, with a prevalence of 4%–38%. Scientific literature is also scarce, reporting hallucinations in children occurring with deriphyllin. To our knowledge, this is the first report which associates deriphyllin use with hallucinations in adults.
| Case Report|| |
An 83-year-old male patient with a history of fall 20 days back with head injury arrived in emergency department with drowsiness, altered sensorium, and left side weakness, along with urine and stool incontinence. On examination, his Glasgow Coma Scale was E3V4M6 with bilateral pupil 1.5 mm and reactive. Power on his right side was found to be 5/5 and left side 2/5. The patient is a known case of recent onset asthma and was on tablet deriphyllin 150 mg BD and salbutamol nebulization BD. The patient was started on antibiotics, analgesics, and antiepileptics. Computed tomography (CT) scan brain was done which showed right frontotemporoparietal subdural hematoma. He underwent emergency drainage of subdural hematoma. The patient's condition improved by evening, and no neurological deficit was found, with movement of all four limbs (power grade 5/5 on the right side and 4/5 on the left side). He was shifted to the ward next day, but he again developed weakness of left side for which CT scan was done which showed recurrent subdural clots for which he again underwent burr holes and evacuation of clots. Within 2 days, left side hemiparesis improved and then the patient was discharged 3 days later with the following medicines: tablet deriphyllin 150 mg BD, tablet levetiracetam 500 mg TDS, tablet metronidazole 400 mg TDS, tablet domperidone 10 mg + pantoprazole 20 mg, tablet folic acid 5 mg OD, tablet sporlac TDS.
On follow-up after 7 days, he was admitted to the emergency department with a complaint of irrelevant talk like driving a scooter and asking people to give him side (hallucination). The patient was subjected to CT brain and electrolytes along with other routine investigations. CT brain showed complete resolution of subdural hematoma. Electrolytes and other routine investigation were within normal range. Tablet levetiracetam was stopped and the patient was put on tablet sodium valproate. Despite this patient's hallucinations continued for next few days, tablet deriphyllin was stopped. After stopping tablet deriphyllin, the patient's condition drastically improved in next few days, and after 1 week, the patient's neurology was completely normal. Dechallenge was positive since the hallucination subsided after discontinuation of offending drug deriphyllin; hence, according to the WHO causality assessment criteria, the reaction was probable/likely due to deriphyllin. This adverse drug reaction (ADR) was reported to the nearest ADR monitoring center with unique ID NO: 2019-48461.
| Discussion|| |
Many factors, both intrinsic (age and disease state) and extrinsic (concurrent drugs, diet, viral infections, and cigarette smoking) affect the biotransformation of the drug in the liver. Some of these factors tend to decrease theophylline elimination, leading to accumulation of the drug in the body and to adverse effects. Genetic factor modifies drug metabolism as well as elimination of theophylline at therapeutic dose. The elderly and the very young are more likely to experience toxicity from the recommended doses of theophylline. In our case, the patient was 83-year-old elderly male, recently started with deriphyllin for recent onset asthma.
After theophylline treatment has been initiated, therapeutic drug monitoring is required. Elderly patients or those with previous brain injury or neurological disease may be at increased risk of neurological changes. Theophylline clearance may be reduced by interaction with various other drugs and the dose of theophylline may need to be reduced to prevent toxic effects. In our case, no potential drug–drug interaction was identified.
Theophylline crosses the blood–brain barrier and mediates effects through blockade of adenosine synthesis and A1-receptor antagonism with consequent relative cellular hypoxia which may aggravate theophylline toxicity.
Theophylline affects the cardiovascular, central nervous (CN), gastrointestinal, pulmonary, musculoskeletal, and metabolic systems. Neurological symptoms include tremors (most common), restlessness, agitation, hallucinations, headaches, irritability, and seizures. In addition to seizures, various types of hallucinations such as visual, auditory, and other psychotic and depressive symptoms have been reported.
The association of hallucinations with theophylline has not been previously reported in adults at therapeutic doses. Baker studied theophylline toxicity in children who showed CN system manifestations including seizures in four patients and visual hallucinations in two patients in acutely intoxicated patients. Neither patient had received any medicine other than theophylline within the previous 24 h, and neither had a febrile illness at the time of presentation. The patient in question here also reported visual hallucination as stated in the case report, but it was with the therapeutic dose.
It is sometimes difficult to establish if hallucination is caused by a drug or by an underlying illness. This is the first case report of deriphyllin-induced hallucination, which was reported at therapeutic doses, and no such cases of deriphyllin-induced hallucination are published previously. Hallucinations in this case resolved promptly after withdrawal of the suspected drug theophylline. Hence, there was a temporal relationship between drug discontinuation and resolving of hallucinations. The elderly, and those with a previous history of psychiatric illness, are at increased risk of drug-induced hallucination. Hallucinations caused by drugs are commonly visual. This occurrence is in concordance with our case. The authors would like to point out a limitation of case report that the theophylline levels could not be measured, so it reduces the strength of association of this ADR to theophylline.
| Conclusion|| |
Physicians should be careful about drugs with narrow therapeutic index like theophylline when prescribed to patients especially in extremes of age. As it is an unusual occurrence at therapeutic dose, a probable genetic factor modifying drug metabolism of deriphyllin could be responsible.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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