LAUSR

To the Editor: Fluoroquinolones are a class of broad-spectrum antibiotics used worldwide. Levofloxacin is a thirdgeneration fluorinated quinolone, which is an optically active L-isomer of racemic ofloxacin. It has a broad spectrum of antibacterial activity against both grampositive and gram-negative bacteria through antagonism of topoisomerase IV and DNA gyrase (topoisomerase II), respectively.1 It is commonly used to treat community-acquired pneumonia, gastrointestinal infections, and urinary infections. Common adverse drug reactions seen with quinolones include gastrointestinal disturbances (nausea and diarrhea) and some central nervous system (CNS) side effects (headache, dizziness, and sleep disturbances), whereas tendinopathy, QTc prolongation, retinal detachment, and severe neuropsychiatric complications are uncommon.2,3 Rare neuropsychiatric adverse reactions reported with quinolones include delirium, agitation, confusion, psychosis, and seizures.2,4–7 The safety profile of the quinolones varies; levofloxacin has a good tolerance profile as compared with other fluoroquinolones.8 We report a case of a middle-aged woman treated with levofloxacin after cholecystectomy, who developed mania that resolved after specific treatment. A 45-year-old woman otherwise fit and well with no premorbidity was diagnosed with acute cholecystitis and underwent laparoscopic cholecystectomy. She received oral levofloxacin 500 mg twice a day during the postoperative period and was discharged after 2 days. She did not sleep for more than 1 hour that night (although she sleeps for 8 hours usually) and was fresh and energetic the following day. After 3 days of neartotal insomnia, she was found to be irritable throughout the day. She claimed herself to be the daughter of “Mariyamma Devar,” an avatar of Lord Krishna, and that she possesses special powers with which she can do anything in this world. According to her, she is present inside Gods and Gods are present in her, and that other people cannot harm her because she is God. She was found speaking out loud and shouted at others if she was interrupted. She was brought to the emergency department with these complaints. There was no psychiatric history, and premorbidly, she was well adjusted. There was no family history of psychiatric disorder. There was no history of fever after surgery or history of any illicit drug use. Physical examination was unremarkable. On mental status, she was irritable with increased psychomotor activity and inattention. She had delusion of grandeur with complete denial of illness. Blood investigations including complete blood count, thyroid function test, liver function test, renal function test, and serum electrolytes were normal. A plain CT scan of the brain was reported to be normal. The clinical presentation was suggestive of acute mania, and considering temporal relationship with levofloxacin administration, organic manic disorder (levofloxacin-induced mania) was considered. On the Naranjo Adverse Drug Reaction Probability Scale,9 the score was 5, suggestive of probable association. She was given oral risperidone 2 mg and lorazepam 2 mg daily with which all the symptoms completely resolved on the next day. She received levofloxacin for the next 2 days. Both risperidone and lorazepam were continued for 1 week and then stopped. There was no recurrence of symptoms at followup after 2 weeks. There was abrupt onset of mania-like symptoms following treatment with levofloxacin that resolved rapidly after treatment with risperidone and lorazepam in our case, suggestive of possible diagnosis of levofloxacin-induced mania. Neuropsychiatric reactions have been reported with levofloxacin, most commonly delirium10–18 and occasionally acute psychosis.19–21 We did not find any report of mania associated with levofloxacin in PubMed using “levofloxacin” and “mania” as search terms. Nevertheless, there are several reports of mania associated with quinolones, specifically with ciprofloxacin, ofloxacin, and norfloxacin (Table 1).22–27 There is a substantial overlap in symptoms of delirium, acute psychosis, and mania associated with quinolones, and in all these conditions, there is a rapid recovery with medication discontinuation, thus raising the possibility that they lie in a continuum. However, most of the case reports of drug-associated acute psychosis and mania have been differentiated from delirium or encephalopathy based on the absence of confusion and disorientation.6,19–21 As distractibility is common in mania, it may be clinically difficult to distinguish this from attentional impairment seen in mild delirium patients. Nevertheless, the presence of Letters to the Editor e371