Mefloquine-induced Paranoid Psychosis and Subsequent Major Depression in a 25-year-old Student

Introduction

Mefloquine hydrochloride, an antimalarial drug used in both prophylactic and therapeutic regimens, is a blood schizontocide that is active against plasmodia in the intraerythrocytic stage and that has no activity against mature gametocytes or against intrahepatic stages of plasmodial development. In humans, prophylactic use of mefloquine (250 mg once weekly) prevents the development of malaria, while single-dose mefloquine therapy with 1000 mg or 1500 mg achieves cure rates of 87 % to 100 % [7].

The absorption half-life is 1 to 4 hours, and the mean peak mefloquine concentration in whole blood or plasma after a single dose is reached after 6 to 24 hours. The terminal elimination half-life ranges from 14 to 28 days in healthy volunteers, indicating that mefloquine is distributed extensively in tissues and is cleared slowly from the body [7].

The drug mefloquine is usually well tolerated, although a number of reversible side effects such as dizziness, nausea, vomiting, diarrhea, headache, abdominal pain, and pruritus have been reported. Neuropsychiatric adverse events such as psychosis, insomnia, seizures and affective disorders have been reported less frequently [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]. The incidence of adverse events is one out of 215 in therapeutic users compared to one out of 13,000 users under prophylaxis, i. e., there is a 60 times higher risk of adverse events after mefloquine treatment than after prophylaxis [10].

We report one case in which severe psychiatric symptoms, e. g., an acute schizophreniform disorder with ideas of persecution, appeared six weeks after mefloquine treatment as prophylaxis, followed by a major depression one month later.

References

• 1 Björkman A. Acute psychosis following mefloquine prophylaxis.  Lancet. 1989/II;  No. 8667 865
• 2 Folkerts H, Kuhs H. Psychotische Episode infolge Malariaprophylaxe mit Mefloquin. Eine kasuistische Mitteilung.  Nervenarzt. 1992;  63 300-302
• 3 Grupp D, Rauber A, Fröscher W. Neuropsychiatrische Störung nach Malariaprophylaxe mit Mefloquin.  Akt Neurol. 1994;  21 134-136
• 4 Hennequin C, Bourée P, Bazin N, Bisaro F, Feline A. Severe psychiatric side effects observed during prophylaxis and treatment with mefloquine.  Arch Intern Med. 1994;  154 2360-2362
• 5 Hollweg M, Soyka M, Greil W. Mefloquininduzierte Psychosen-Probleme der Kausalzuordnung anhand zweier kasuistischer Berichte.  Psychiatrische Praxis. 1995;  22 33-36
• 6 Luxemburger C, Nosten F. et al . Mefloquine for multidrug-resistant malaria.  Lancet. 1991;  338 1268
• 7 Palmer K J, Holliday S M, Brogden R N. Mefloquine-A review of its antimalarial activity, pharmacokinetic properties and therapeutic efficacy.  Drugs. 1993;  45 430-475
• 8 Rubner O. Provokation einer schizophrenen Psychose durch Mefloquinhydrochlorid.  Psychopharmakotherapie. 1994;  1 54-56
• 9 Steffen R, Fuchs E, Schildknecht J, Naef U, Funk M, Schlagenhauf P, Phillips-Howard P, Nevill C h, Stürchler D. Mefloquine compared with other malaria chemoprophylactic regimens in tourists visiting East Africa.  Lancet. 1993;  8856 1299-1303
• 10 Weinke T h, Trautmann M, Held T H, Weber G, Eichenlaub D, Fleischer K, Kern W, Pohle H D. Neuropsychiatric side effects after the use of mefloquine.  Am J Trop Med Hyg. 1991;  45 86-91