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Acute Psychosis Following the Use of Topical Ciprofloxacin
Arch Ophthalmol. 2002;120:665-666.
INTRODUCTION
Ciprofloxacin hydrochloride is a fluoroquinolone antimicrobial frequently
used in both ophthalmic and general medical practice. Whereas adverse effects
of this drug are not uncommon following its systemic use, they are uncommon
following its topical use. We present the case of a young woman who developed
an acute psychotic reaction following the use of ciprofloxacin eyedrops. To
our knowledge, this is the first reported case of such a complication following
topical ciprofloxacin use.
Report of a Case
An otherwise fit and healthy 27-year-old woman came to the emergency
eye clinic with a 3-day history of bilateral reddened eyes associated with
ecchymosis and swelling of the eyelids. There was no history of pain or impairment
of vision. Examination results revealed severe bilateral conjunctival congestion,
marked papillary reaction, and membranous conjunctivitis. The results of the
remainder of the ocular examination were entirely normal and there was no
lymphadenopathy. The patient had no history of any systemic complaints, was
taking no medication for therapeutic or recreational use, did not have alcoholism,
and did not smoke. Conjunctival swabs were taken and sent for microbial isolation
and sensitivity assays and the patient was prescribed ciprofloxacin eye drops,
1 drop hourly, in each eye. About a half hour after the third dose, the patient
complained of dizziness and light-headedness. Following this, family members
noted a distinct change in the behavior of the patient, who began to have
well-defined visual hallucinations, ill-defined auditory hallucinations, and
irrational conversation. The next day, the patient was seen in the emergency
eye department, accompanied by her mother, with increasing behavioral problems.
A psychiatric opinion was sought. The patient was deemed to have had an acute
psychotic reaction secondary to topical ciprofloxacin. The patient was advised
to stop using ciprofloxacin eye drops (nearly 24 hours after initiation of
treatment) and began taking teicoplanin (1%) eye drops. Within about 12 hours
of changing the treatment, the patient and family members noted an improvement
in behavior and within a further 12 to 14 hours, the hallucinations and behavioral
disturbances disappeared completely. The patient was later able to describe
her visual and auditory hallucinations in detail. The conjunctivitis responded
completely to the teicoplanin regimen.
Comment
Ciprofloxacin is a fluoroquinolone antimicrobial that inhibits DNA gyrase,
and when given orally, exhibits 70% bioavailability and attains peak serum
levels ranging between 1.5 and 2.9 µg/mL after a single 500-mg dose,
with 19% of an oral dose being excreted as metabolites in both urine and feces.1 In addition to cutaneous and gastrointestinal
adverse effects, central nervous system adverse effects, such as dizziness
and lightheadedness,2 acute psychosis,
and other neuropsychiatric disorders3-4
have been described following its systemic use. In extremely rare situations, more serious central nervous system effects,
such as seizures, have also been described.4
Cases of ciprofloxacin-induced psychosis have been reported, with resolution
of psychotic symptoms on discontinuation of the drug5
and reappearance of these symptoms on resumption of ciprofloxacin treatment.6 However, to our knowledge, there is no report
of these adverse effects following the use of topical ciprofloxacin eye drops.
In the case reported here, we believe that the systemic adverse event experienced
by this patient was an idiosyncratic one, aided by the increased systemic
absorption of the drug secondary to severe conjunctival inflammation. Although
the patient did not resume use of the topical ciprofloxacin, the absence of
other confounding illnesses (drug or alcohol abuse and previous psychiatric
disturbances) and the rapid resolution of psychosis support the case for topical
ciprofloxacin as the causative factor. Whereas psychotic reactions are well
known after the use of atropine7-8
and cyclopentolate9 eye drops, this is
the first reported case, to our knowledge, of such a reaction after the use
of ciprofloxacin eye drops. Therefore, the possibility of such an adverse
effect should always be kept in mind in patients using these drops, particularly
in young women, who seem to be especially sensitive to these effects.2
AUTHOR INFORMATION
Ajay Tripathi, MS, FRCS(Ed), FRCS(Glas)
Birmingham, England
Sean I. Chen, MRCOphth;
Sheila O'Sullivan, MRCPsych
Liverpool, England
Corresponding author: Ajay Tripathi, MS, FRCS(Ed), FRCS(Glas), Birmingham
and Midland Eye Hospital, City Hospital, Dudley Road, Birmingham B18 7QU,
England.
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SECTION EDITOR: W. RICHARD GREEN, MD
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