Psychotic mania after sudden discontinuation of high-dose corticosteroids

To the Editor

Although corticosteroid-related neuropsychiatric symptoms (NPS) are common, they are complex and unpredictable, with the related psychopathology ranging from anxiety to psychosis (Warrington and Bostwick, 2006). NPS are typically associated with high doses of corticosteroids and usually develop within the first weeks of treatment (Dubovsky et al., 2012). We report a patient presenting with psychotic mania following the abrupt discontinuation of corticosteroid therapy.

Mr A, a 55-year-old man, with no personal or familial psychiatric history, entered the emergency room, exhibiting severe psychomotor agitation and aggression. He pounded on the office desk and claimed that if he did not kill his cat at midnight, his mother-in-law could not enter heaven. Following his admission, Mr A lacked insight and expressed delusions of reference, persecution and misidentification.

Blood tests (including N-methyl-d-aspartate receptor [NMDAR] antibodies), lumbar puncture, brain magnetic resonance imaging (MRI) and electroencephalography (EEG) showed no abnormalities. However, we were informed that Mr A was given a 6-week course of prednisolone (60 mg/day), as a treatment for posterior uveitis. Given the lack of a prednisolone prescription, Mr A suspended treatment after that time. His erratic behaviour began a week after corticosteroid discontinuation. Mr A expelled family members from the house during a dinner party. Over the following week, he presented with pressured speech, a decreased need for sleep, extreme irritability and periods of euphoria. He also displayed uncharacteristically disinhibited and impulsive behaviours. The day he arrived at the emergency room, he started a bonfire in his backyard and burnt all of his electronic devices.

Mr A was treated with risperidone (4 mg/day) and benzodiazepines. Prednisolone was reinstated and slowly reduced to prevent adrenal insufficiency. One week later, Mr A was calm and able to recognize that his behaviour had been bizarre and out of character.

While somatic adverse effects of corticosteroid treatments have been extensively investigated, the neuropsychiatric counterparts have received less attention (Warrington and Bostwick, 2006). Although NPS usually arise within the first days following the initiation of corticosteroid treatment, this may not always be the case. Our report underscores the need for active vigilance across all treatment stages, including after discontinuation. We found one report of a similar nature, despite its broadened use of the term ‘psychosis’ (Mercadante et al., 2007). Clinicians prescribing high doses of corticosteroids must be aware of the associated neuropsychiatric complications. Informing patients and their families about these potential symptoms could help to prevent delays in both evaluation and treatment.