Persistent mania following cessation of corticosteroids.

OBJECTIVES: The aims of this study are to describe two patients whose manic symptoms persisted for several months after the cessation of corticosteroids, to review the literature and to suggest treatment. METHODS: The presentation of two elderly patients with persistent manic symptoms following cessation of corticosteroids several months previously afforded the author the opportunity to examine them carefully, investigate and treat them. RESULTS: The patients were investigated to rule out other causes and were treated with sodium valproate and quetiapine (in the second patient). When well, the medications were slowly decreased and stopped. Both patients were well at one-year follow-up. CONCLUSIONS: Manic symptoms may persist for many months after stopping corticosteroids and active treatment is needed to control them.

Laennec's melanosis: The first published description of metastatic melanoma.

Melanomas are a common skin condition in Australia. The authors decided to examine the history of melanomas and its metastases with particular reference to the description of Laennec and the controversy between him and his teacher Dupuytren, who challenged his pupil as to who was the first to describe melanomatous metastases to the lungs. The rivalry between teacher and student continued, with each describing a similar system of pathological classification.

Renal replacement therapy associated with lithium nephrotoxicity in Australia.

OBJECTIVE: To analyse the annual incidence of end-stage renal disease (ESRD) associated with lithium-induced nephropathy (LiN) in Australia. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study of patients commencing renal replacement therapy (RRT) in Australia. We compared patients with LiN with all other RRT patients between 1 January 1991 and 31 December 2011, using Australia and New Zealand Dialysis and Transplant Registry data. MAIN OUTCOME MEASURES: Numbers and characteristics of incident RRT patients, primary kidney disease (LiN or other, based on clinical diagnosis). RESULTS: LiN contributed to 187 people in Australia commencing RRT between 1 January 1991 and 31 December 2011. The incidence rate increased from 0.14 cases/million population/year (95% CI, 0.06-0.22) in 1992-1996 to 0.78 (95% CI, 0.67-0.90) in 2007-2011. This increase is unlikely to be attributed solely to demographic changes in Australia. LiN patients were more likely than non-LiN patients to be women, to be white, to smoke, and to have a higher body mass index, but were less likely to have undergone renal biopsy. CONCLUSIONS: Rates of ESRD attributed to LiN are increasing rapidly. Currently accepted lithium dosages and duration of treatment might induce ESRD in a large cohort of patients. We encourage clinicians to exercise discretion when prescribing lithium, check renal function regularly, stop lithium if there is a deterioration in two consecutive readings, and consider substitution with other drugs.

Antisocial behaviour and lying: a neuropsychiatric presentation of agenesis of the corpus callosum.

OBJECTIVE: The purpose of this case study is to describe the case of a person with agenesis of the corpus callosum (ACC), intellectual disability and features of antisocial behaviour and lying. METHODS: A 26-year-old woman with a mild intellectual disability who presented with antisocial behaviour and chronic lying was found to have ACC and associated cerebral abnormalities. RESULTS: Psychiatric, radiological and neuropsychological assessment of this patient provided convergent evidence of the importance of the corpus callosum in enabling understanding of social situations and appropriate social behaviour, particularly via its connectivity with the frontal regions of the brain. CONCLUSION: Antisocial behaviour and lying may be more commonly associated with callosal dysgenesis than is currently realised.

William Siegfried Dawson: a pioneering Australasian psychiatrist.

OBJECTIVE: The purpose of this paper was to consider the life and contribution of Professor William Siegfried Dawson (1891-1975) by examination of school, university and hospital reports and journal articles. CONCLUSIONS: Professor Dawson made a major contribution, through his academic and professional roles and leadership, to the firm establishment of psychiatry, psychiatric scholarship and psychiatric organisations in Australia.

Rapid reversal of corticosteroid-induced mania with sodium valproate: a case series of 20 patients.

BACKGROUND: Glucocorticoids are widely used in medicine and are known to cause psychiatric side effects, including mania. There is anecdotal evidence that sodium valproate is effective for treating psychiatric side effects of glucocorticoids. OBJECTIVE: To describe a case series of 20 patients receiving corticosteroids for various medical conditions who developed manic-like symptoms. They were treated with sodium valproate while continuing on corticosteroids. METHOD: Patients treated with corticosteroids who reported to their physician subjective distress or who were openly disruptive in the ward were assessed by a consultation-liaison psychiatrist on the same day with the Young Mania Rating Scale. Immediately afterwards, blood was taken to measure the cortisol or dexamethasone level and then started on sodium valproate 500 mg twice daily. Valproate levels were measured on day 3 to adjust the dose. RESULTS: There was a significant, rapid improvement of symptoms within 48 hours after sodium valproate was initiated. Within 72 hours all patients were euthymic and remained so over the ensuing week. The only major side effect was hyperammonemia in 1 case which resolved when valproate was stopped. CONCLUSIONS: This case series shows that sodium valproate is a safe medication that rapidly reverses manic-like symptoms within a few days without needing to stop the corticosteroids, thus allowing the medical treatment to continue. The ability to continue treatment while controlling or ameliorating the psychiatric side effects of glucocorticoids with sodium valproate is an advance over previous approaches. The mechanism of this rapid action is unclear and deserves further study.

Venlafaxine hyponatraemia: incidence, mechanism and management.

OBJECTIVE: This prospective study was performed on patients aged >65 years commencing therapy with venlafaxine, in order to determine the incidence of hyponatraemia induced by the drug, to investigate the underlying pathophysiological mechanisms, and to evaluate a simple approach to management of this condition. METHOD: All patients aged >65 years seen by one author (MR) from all referral sources were entered into the study. Baseline biochemical tests were ordered, and if hyponatraemia developed (plasma Na <130 mmol L(-1)) additional tests were performed to ascertain the mechanism, while the patient continued on venlafaxine and fluid restriction was instituted. RESULTS: A total of 58 patients were seen, of whom 10 developed hyponatraemia, giving an incidence of 17.2%. Of these 10 patients, five were excluded from prolonged observation because of either severe medical illness, side-effects from the antidepressant or being lost to follow up. When hyponatraemia developed, it invariably did so within a few days of starting venlafaxine, and was associated with non-suppression of antidiuretic hormone in the face of a low serum osmolality. Fluid restriction (800 mL day(-1)) was effective in raising the plasma sodium to the normal range within 2 weeks, after which the fluid restriction could be relaxed without relapse occurring. These patients remained well for the follow-up period of up to 6 months. CONCLUSIONS: Patients >65 years of age should have their electrolytes measured 3-5 days after starting venlafaxine therapy. If hyponatraemia develops, it can be managed with modest fluid restriction without discontinuing drug treatment, subject to close continued clinical observation and biochemical monitoring.