Neuropsychiatric reaction induced by clarithromycin in a patient on highly active antiretroviral therapy (HAART)

Case report: cobblestoneNeuropsychiatric reaction induced by clarithromycin in a patient on highly active antiretroviral therapy (HAART) K Prime, P French Case history A 58 year old man, diagnosed HIV-1 antibody positive 3 years previously, presented with a 24 hour history of hyperactivity.This culminated in the development of suicidal and homicidal ideation.For fear of injury to himself and others he was admitted to hospital.He had commenced a course of clarithromycin by mouth 500 mg twice daily 10 days previously, for a bacterial chest infection.Two months before this, HAART had been commenced with zidovudine by mouth 250 mg twice daily, didanosine by mouth 200 mg twice daily, and nevirapine by mouth 200 mg twice daily.This was in addition to long term treatment with simvastatin by mouth 20 mg once daily for hypercholesterolaemia.There was no other medical history of note.He also had no previous history of mental ill health, alcohol, or drug misuse.On physical examination, he was afebrile with oxygen saturations of 100% on air.His pulse was regular at 80 beats/minute and blood pressure 110/60 mm Hg.Examination of his respiratory and gastrointestinal systems was unremarkable.Neurological examination was unremarkable apart from mental state assessment which showed hyperactivity manifested as pressure of speech, poor concentration, and extreme anxiety.He also expressed suicidal and homicidal ideation into which he maintained insight.Investigations including full blood count, urea and electrolytes, liver function tests, calcium, phosphate, and glucose were normal.Blood culture, Toxoplasma gondii serology, treponemal haemagglutination assay, and serum cryptococcal antigen were negative.HIV viral load was <500 copies/ml and CD4 count 480 × 10 6 /l.Drug levels were not measured.A diagnosis of a severe neuropsychiatric reaction secondary to clarithromycin was made.Clarithromycin was discontinued and he was treated with diazepam by mouth 5 mg twice daily and temazepam by mouth 20 mg at night.Twenty four hours after admission he remained only mildly hyperactive with no further suicidal or homicidal ideation.After 72 hours his symptoms had resolved completely and he was discharged.