We would like to report on a case that highlights the importance of maintaining a high index of clinical suspicion in a patient with sudden onset of psychiatric symptoms. The patient, an obese 44-year-old woman with a history of hypertension, was seen in the emergency room for the acute onset of pressured and disorganized speech, coprolalia, insomnia, sexual disinhibition, and elevated mood.
A review of her history revealed that a month earlier, she had started taking a daily compounding drug (components included artichoke, Centella asiatica, chlordiazepoxide, Rhamnus purshiana, furosemide, phenolphthalein, Hoodia gordonii, and metformin) and hydrochlorothiazide 50 mg once a day, both prescribed by a doctor for peripheral edema.
Blood work showed hyponatremia (120 mmol/L) and hypokalemia (2.8 mmol/L). A computed tomography scan was normal.
The patient was admitted to the hospital and given potassium chloride and electrolytic physiological serum for correction of fluid and electrolyte imbalances, and quetiapine 300 mg once a day. She was discharged 5 days later, with fluid and blood ion balance restored and symptoms resolved. One month later, the quetiapine was stopped. Six months after discharge, she remains asymptomatic, with no functional deficits.
Blood ion imbalance is known to cause behavioral alterations, and cases of hyponatremia-induced mood changes or psychosis have been reported.1,2 A case of hypokalemia-induced psychosis in a patient with schizophrenia has been reported,3 but there are no reports of such changes in a nonpsychiatric patient, such as ours.
In our patient, the acute onset and type of symptoms, the absence of previous similar episodes, her age, the blood ion imbalance at admission, and the fast clinical improvement along with blood analytic normalization and the absence of psychiatric symptoms 6 months later support a diagnosis of hyponatremia/ hypokalemia-induced hypomania.
Luís Fonseca, MD
Filipa Pereira, MD
Joaquim Duarte, MD
Psychiatry and Mental Health Department,
Braga Hospital, Portugal