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AJR 2002; 178:766-767
© American Roentgen Ray Society

Premedication Before IV Contrast-Enhanced CT Resulting in Steroid-Induced Psychosis

Benoît Mesurolle, Michèle Ariche and David Cohen

Institut Gustave-Roussy F-94805 Villejuif Cedex, France
Groupe Hospitalier Pitié-Salpétrière F-75013 Paris, France

We read with interest the article by Freed et al. [1], in the June 2001 issue of the American Journal of Roentgenology on the adverse reactions to low-osmolar contrast media after steroid premedication. We would like to take the opportunity to report an unusual adverse effect of steroid premedication that we encountered in a young female patient with bipolar disorder. A 13-year-old girl was brought to a psychiatric unit with a diagnosis of maniac episode with psychotic features. Chlorpromazine and tropatepine were started, and carbamazepine was added on day 14. On day 16, symptoms improved dramatically. Electroencephalography and unenhanced CT of the head showed no abnormalities. Because the patient had a history of adverse reaction to contrast material, radiologists prescribed a 3-day treatment using methyl-prednisolone (32 mg/day) and ranitidine (300 mg/day) from day 18 to day 20, before she underwent contrast-enhanced CT of the head. Her psychiatric symptoms suddenly reappeared on day 19, and they were more severe than initially, including extreme agitation and mental confusion. Because the patient had shown no improvement, all drugs were discontinued on day 26. A new treatment was started that used both haloperidol and lithium carbonate. Her manic symptoms improved from day 31, and the patient was euthymic at discharge 2 weeks later.

In this case, according to the French method used for assessment of unexpected or toxic drug reaction [2], it is likely that the recurrence of manic symptoms in this patient with bipolar disorder was a consequence of the methylprednisolone or ranitidine. Published data support the role of the glucocorticoid, because ranitidine has not been reported as a cause of manic reaction [3]. The exacerbation of maniac symptoms following exogenous glucocorticoid administration is not a new phenomenon. It has been reported in the adult literature, but never in a case of short-term premedication before contrast-enhanced radiologic examinations. On one hand, many studies report the frequency and nature of adverse reactions to contrast media even after steroid premedication. On the other hand, only anecdotal articles report adverse or unusual effects of steroid premedication before contrast-enhanced CT. Wong et al. [4] reported a case of resolution of lymphadenopathy in a patient with lymphoma, after short-term steroid premedication.

To the best of our knowledge, this psychiatric complication after steroid premedication has not been reported previously. This case shows that even short-term doses of steroid may have a significant adverse effect on patients with a history of mood disorders. Caution is advised when instituting steroid premedication in these patients. Such premedication may induce exacerbation of mood symptoms, even when patients are under mood stabilizers [5].

References

  1. Freed KS, Leder RA, Alexander C, DeLong DM, Kliewer MA. Breakthrough adverse reactions to low-osmolar contrast media after steroid premedication. AJR 2001;176:1389 -1392[Abstract/Free Full Text]
  2. Moore N, Biour M, Paux G, et al. Adverse drug reaction monitoring: doing it the French way. Lancet 1985;2:1056 -1058[Medline]
  3. Long TD, Kathol RG. Critical review of data supporting affective disorder caused by nonpsychotrophic medication. Ann Clin Psychiatry 1993;5:259 -270[Medline]
  4. Wong TZ, Levine JD, Safer M, Jones EL. Steroid premedication before IV contrast-enhanced CT resulting in resolution of lymphadenopathy. AJR 1998;170:218 -219[Medline]
  5. Siegel FP. Lithium for steroid-induced psychosis. N Eng J Med 1978;299:155 -156[Medline]

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This Article
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Right arrow Articles by Cohen, D.
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