Complex hallucinations induced by lamotrigine

NEUROL-2046; No. of Pages 2 revue neurologique xxx (2018) xxx–xxx Available online at ScienceDirect www.sciencedirect.com Letter to the Editor Complex hallucinations induced by lamotrigine Lamotrigine is an antiepileptic drug with large-spectrum efficacy in several forms of partial and generalized epilepsy and is also known as a mood-stabilizing medication used in bipolar disorder. The most described side effect of lamotrigine is allergy. Psychiatric manifestations are extremely rare reactions and only a few similar case reports are reported in the literature. We present a case of complex hallucinations with tactile and visual patterns induced by lamotrigine in an epileptic patient. Mrs. D.E. is a 73-year-old woman with a history of a stroke caused by atrial fibrillation, vascular epilepsy with generalized seizures treated recently by lamotrigine. The first week after starting lamotrigine (25 mg once daily), Mrs. D. developed tactile hallucinations that increased with dose increase. She described sensations of ‘‘tiny insects coming out from her anus and crawling over her skin, and she had to close it with paper, otherwise, the insects spread all over her body, hair, clothes.’’ Her behaviour was exaggerated; she developed obsessive compulsive disorders (OCD) behaviour with cleaning/washing compulsions and started to have a visual hallucinations (seeing strangers around the room). She has been seizure-free for 6 months. Electroencephalogram (EEG) during the psychotic episode was normal. Her tactile and visual hallucinations caused significant anxiety to her and mandated the switch to levetiracetam with reduction and withdrawal of lamotrigine, which led to the complete cessation of psychotic symptoms in 3 weeks. We initially discussed whether these symptoms should be considered as the side effects of lamotrigine. Otherwise, they may be an epileptic manifestation or onset of chronic psychiatric disease. Our patient had been seizure-free for at least 6 months before the onset of the psychotic episode, so we could not attribute it to post-ictal psychosis. Also, the timesliced character of the beginning of hallucinations and its relationship with the introduction of lamotrigine led us to think of a toxic drug origin. Moreover, rapid remission of psychotic symptoms after dose reduction and withdrawal was observed. All these features lead to the conclusion that any hallucination, even minimal, maybe an uncommon adverse effect of lamotrigine, and thus its incrimination must be mentioned. We found this case interesting enough to share it, in order to participate in patient education about this rare but alarming side effect, to improve medication adherence and avoid unnecessary treatment. As found by other authors, hallucinations are atypical adverse effects of Lamotrigine, described by Weintraub [1] in a study of 546 patients with epilepsy, that reported 4.8% incidence of psychiatric and behavioural side effects with lamotrigine. A literature review by Villari et al. [2] documented acute psychotic episodes with lamotrigine in patients with or without a history of epilepsy [3–5] (Table 1). Even if its mechanism still not clear, we hypothesized that sodium channel blockade has a role in the generation of Table 1 – Literature review by Villari et al. [2] documented acute psychotic episodes with Lamotrigine in patients with or without a history of epilepsy [3–5]. Authors n Main behavioural manifestations Weintraub et al. [1] 546 (4,8%) Villari et al. [2] (literature review) Desarkar and Sinha Savas et al. Margolese et al. Raskin et al. Brandt et al. Matsuo et al. Roberts et al. 1 2 1 2 6 216 (4) 1 Brodie MJ et al.[3] 131 (6%) Anxiety, behavioural change, depression, irritability/moodiness, or psychosis Acute psychotic episodes, hallucinations and affective switching Affective switch Maniac episode Mood lability Agitation, mood change, delusions Paranoid thoughts, visual and auditory hallucinations, agitation and sleep disturbances Psychotic episode, delusion Visual hallucinations Insomnia, Irritability, anxiety, hypomania Please cite this article in press as: El Otmani H, et al. Complex hallucinations induced by lamotrigine. Revue neurologique (2019), https://doi.org/ 10.1016/j.neurol.2018.11.004 NEUROL-2046; No. of Pages 2 2 revue neurologique xxx (2018) xxx–xxx hallucinations, in addition to an idiosyncratic reaction toxicity as a result of the concomitant use of another drug that affects lamotrigine metabolism (sodium valproate, felbamate). As our case is purely observational, further studies are necessary in order to characterize possible toxic or intrinsic psychogenic properties of lamotrigine. Disclosure of interest The authors declare that they have no competing interest. references [1] Brodie MJ, Richens A, Yuen AW. Double-blind comparison of lamotrigine and carbamazepine in newly diagnosed epilepsy. UK lamotrigine/carbamazepine monotherapy trial group. Lancet 1995;345:476–9. [2] L.J. Stephen, A. Wishart, M.J. Brodie. Psychiatric side effects and antiepileptic drugs: observations from prospective audits. Epilepsy & Behavior 2017;71:73–8. [3] Schmitz B. Effects of antiepileptic drugs on mood and behavior. Epilepsia 2006;47(Suppl. 2):28–33. [4] Villari V, Rocca P, Frieri T, et al. Psychiatric symptoms related to the use of lamotrigine: a review of the literature. Funct Neurol 2008;23(3):133–6. [5] Weintraub D, Buchsbaum R, Resor Jr SR, Hirsch LJ. Psychiatric and behavioral side effects of the newer antiepileptic drugs in adults with epilepsy. Epilepsy & Behavior 2007;10:105–10. H. El Otmania,b,* R. Amzila,b M.-A. Rafaia,b B. El Moutawakila,b a Neurology and Neurophysiology department, Ibn Rochd University Hospital, 20000 Casablanca, Morocco b Faculty of Medicine and Pharmacy Hassan II, University of Casablanca, 67, rue Abou-Alaa Zahr, N820, 20000 Casablanca, Morocco *Corresponding author at: Faculty of Medicine and Pharmacy Hassan II, University of Casablanca, 67, rue Abou-Alaa Zahr, N820, 20000 Casablanca, Morocco. E-mail address: hichamotmani@hotmail.com (H. El Otmani) Received 24 August 2018 Received in revised form 24 October 2018 Accepted 9 November 2018 Available online xxx https://doi.org/10.1016/j.neurol.2018.11.004 0035-3787/# 2019 Elsevier Masson SAS. All rights reserved. Please cite this article in press as: El Otmani H, et al. Complex hallucinations induced by lamotrigine. Revue neurologique (2019), https://doi.org/ 10.1016/j.neurol.2018.11.004