Inhaled Steroid–Induced Mania in an Adolescent Girl: A Case Report

To the Editor: Beclomethasone is a synthetic, halogenated glucocorticoid with anti-inflammatory and vasoconstrictive effects. Its inhaled form is used for the treatment of asthma, allergic and nonallergic rhinitis, and viral croup.1 It accomplishes this by inhibiting leukocyte infiltration and suppressing the humoral immune response. The mechanism of the anti-inflammatory properties of corticosteroids is believed to involve phospholipase A2 inhibitory proteins and lipocortins, which regulate the biosynthesis of inflammatory mediators such as prostaglandins and leukotrienes.2 Excretion of beclomethasone is mainly fecal, and, generally, the drug is well tolerated. The risk of adrenal suppression is more associated with the usage of systemic steroids.3

Psychiatric symptoms associated with corticosteroid therapy include mood swings, mania, hypomania, and depression.4 Mania and hypomania are more common than depression.4 The association of adverse psychological side effects with the use of oral and systemic steroids has been well documented in both the adult and the pediatric populations.413 To our knowledge, there are at least 6 case reports published in which the isolated use of inhaled corticosteroids (beclomethasone dipropionate and budesonide) led to the development of psychiatric symptoms in the pediatric population.12,1419 In most cases, symptoms occurred in the first week, and the most commonly reported symptoms are insomnia, aggressiveness, uninhibited behavior, mania, irritability, and increased energy.12,1419 In most cases, the symptoms resolved after discontinuation of the drug, switching to another drug, or decreasing the dosage.12,1419

Case report. Ms A, a 16-year-old white girl with no significant past psychiatric history, presented to an outpatient psychiatric clinic in 2010 with acute mania. The patient had grandiosity (“God gave me the mission to save the world”), flight of ideas, impulsivity (self-mutilating behavior), racing thoughts, pressured speech, decreased need for sleep, and high energy. On mental status examination, she reported a euphoric mood and described delusions of grandiosity. She denied experiencing any hallucinations. She had pressured speech and her affect was mood-congruent.


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