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J Vector Borne Dis 46, March 2009, pp. 81–82 Case Report
Toxic psychosis due to chloroquine overdose : a case report Syed Ahmed Zaki, Anupama Mauskar & Preeti Shanbag Department of Pediatrics, Lokamanya Tilak Municipal General Hospital, Mumbai, India Key words Chloroquine overdose – malaria – psychosis
Malaria is an endemic disease in developing coun- understand the dosing schedule they took four tab- tries like India. Peripheral smear examination for lets of chloroquine immediately followed by two tab- malarial parasites, though the gold standard for diag- lets every two hourly for the next 12 h. Thus, the total nosis is observer-dependent and may be reported as dose of chloroquine which the child received was 1.5 negative even in strongly-suspected cases. Hence, a g on the first day. The total dose of chloroquine re- large number of patients having fever are empirically ceived by the child was approximately 100 mg/kg of treated with antimalarial drugs. Chloroquine and its base as against the total therapeutic dose of 25 mg/ derivatives have been the drugs of choice in the pro- kg of base. Paracetamol was given in the correct phylaxis and treatment of uncomplicated malaria for dose. The medication was discontinued from the sec- over many years. Common side-effects of chloro- ond day as the fever subsided. Developmentally the quine are nausea, vomiting and unpleasant taste.
child was normal and she was studying in 2nd stan- Central nervous system adverse events following dard and was good in her studies. Birth and family chloroquine have been described1–4. We herein re- port a child who developed psychosis following chlo-roquine overdose.
On admission the child was afebrile with a heart rateof 100/min and respiratory rate of 24/min. Her blood A 7-year-old female child was admitted with com- pressure was 100/70 mm Hg in the right upper arm plaints of abnormal behaviour in the form of exces- in the supine position. There was no icterus, pallor sive talking and restlessness one day prior to or rash on general examination. There were no stig- admission. She had a history of high-grade fever with mata of neurocutaneous disorders. Central nervous chills, and vomiting five days back. For these com- system examination revealed a restless child with plaints the child was taken to a private practitioner uninhibited behaviour. Her comprehension was nor- who started her on chloroquine and paracetamol.
mal and she was able to follow instructions. She was There was no history of convulsion, icterus, loose well-oriented in time, space and person. The child motions, cough, cold or abdominal pain. There was spoke excessively but speech was not slurred. She no history of contact with tuberculosis or head injury.
had normal cranial nerve examination. Her motor There was no history of similar episodes in past or and sensory examination was normal. Deep tendon in other family members. There was no preceding and superficial reflexes were normally elicited. There stressful event at home or in school. As per the pre- were no meningeal or cerebellar signs. No other ab- scription given by the doctor the dose of tablet chlo- normalities were detected on systemic examination.
roquine (base 150 mg) was 10 mg/kg followed by 5 Her complete blood count, liver function, renal func- mg/kg at 6, 24 and 48 h. But as the parents didn’t tion tests and serum electrolytes were normal.
OptiMal test done for malaria was also negative.
take of 1–6 g of chloroquine and occurs between twoand 40 days after the intake1. The exact mechanism A diagnosis of chloroquine-induced psychosis was of chloroquine-induced psychosis is not known but made. A psychiatry reference was taken and the child the role of different neurotransmitter systems— was started on tablet olanzapine 10 mg/day. The child polyamines (especially spermidine) excess, dopam- was discharged at request on the 4th hospital day. She ine excess, acetylcholine imbalance and prostaglan- has been following up regularly and is normal at last din-E antagonism have been postulated. The duration of behavioural changes ranges from two days to eightweeks1. The treatment of mania due to chloroquine Chloroquine is given in an initial dose of 10 mg base/ overdose is supportive and includes antipsychotic kg/body weight followed by either 5 mg/kg at 6, 24 medications like olanzapine as long as the patient is and 48 h, or more commonly by 10 mg/kg on the second day and 5 mg/kg on the third day5. Such adosing schedule is uncommon in office practice and We conclude that chloroquine overdose can cause is difficult to comprehend. Hence, due to a commu- psychosis and should be used cautiously in the treat- nication gap and the uncommon dosing schedule, ment of malaria. The adverse effects due to overdos- patients tend to either take less or more doses of chlo- age can persist for several weeks. We highlight the roquine. Chloroquine has a low safety margin and is need for proper instruction by doctors when prescrib- ing chloroquine for malaria and the need to check thatthe parents have understood the dosing schedule.
Central nervous system toxicity includes convulsionsand mental changes. Other uncommon effects are References
retinopathy, myopathy, reduced hearing, photosen-sitivity, loss of hair and aplastic anaemia. Acute over- 1. Bhatia MS, Malik SC. Psychiatric complications of chlo- dosage is extremely dangerous and death can occur roquine. Indian Pediatr 1995; 32: 351–3.
within a few hours. The fatal dosage reported in the 2. Akhtar S, Mukherjee S. Chloroquine induced mania. Int J literature is as little as 1 g of chloroquine phosphate Psychiatry Med 1993; 23: 349–56.
in children and 6 g in adults1. The patient may also 3. Garg P, Mody P, Lall KB. Toxic psychosis due to chloro- develop electrolyte disturbances, hypotension and quine—not uncommon in children. Clin Pediatr 1990; 29: 4. Bhatia MS. Chloroquine induced psychiatric complica- In a patient with malaria, psychosis could be due to tions. Br J Psychiatry 1991; 159: 735.
the fever itself or the antimalarial drug administered.
5. Guidelines for the treatment of malaria. Geneva: World In our patient, psychosis was probably secondary to Health Organization. Available from: chloroquine overdose since it appeared two days af- malaria/docs/TreatmentGuidelines2006.pdf. ter the fever had subsided and three days after an in- 6. Vacheron-Trystram MN, Braitman A, Cheref S, Auffray take of 1.5 g of chloroquine. Psychosis due to L. Antipsychotics in bipolar disorders. Encephale 2004; chloroquine has been reported to appear with an in- Corresponding author: Dr Syed Ahmed Zaki, Department of Pediatrics, Lokamanya Tilak Municipal General Hospital, Mumbai–400 022, India.


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