Case report:
A 24-year-old, single, gentleman, with a diagnosis of Carcinoma (CA)
Rectum, underwent surgery followed by chemoradiotherapy at our center.
While he was on adjuvant chemotherapy of 3rd cycle,
with a combination of capecitabine and oxaliplatin (CapOX regimen as per
the schedule- Oxaliplatin was given intravenously as an inpatient dose
calculated as body weight followed by T.Capecitabine to be taken orally
by the patient twice daily for 14 days in each cycle). The oncology team
started observing changes in his behavior after 3rdday of the 3rd cycle of chemotherapy. He started
having awake nights with a duration of sleep up to three hours per night
and overfamiliarity with strangers. Despite resuming his routine work,
he was found to be excessively involved in cycling, physical exercise,
and studying which wasn’t his usual self. He started believing in
various businesses investment while working at the grocery shop and
would not be productive with customers due to excessive involvement in
the tedious detailing of the transactions. During this week he was found
to be overgrooming and expressing increased attraction towards female
friends than his usual self. These behavioral changes resulted in
frequent reminding by family members and eventually stopped him from
attending the shop. Considering changes in his usual self and insistence
by the family, he discontinued the oral capecitabine for 4 days this
phenomenon was consistent with the self-dechallenge. By the end of
4th day, the family found that he could sleep well at
night and he appeared calmer. The patient also noticed that he could
fall asleep easily (sleep latency reduced to 10-15 minutes than 45-60
minutes earlier) and could feel fresh the next morning. Barring his
biological functions, even after 5 days of stopping the capecitabine, he
was over cheerful and overtalkative.
Patient-reported to oncology team and capecitabine was rechallenged as a
part of treatment regimen while advising brief inpatient care to note
the progression of affective symptoms. After rechallenging with the
capecitabine, over the next two days, his behavioral problems worsened
and he was referred to the Consultation-Liaison Psychiatry (CLP) team.
After a detailed evaluation, it was evident that the patient had no
significant past history of any psychiatric illness. A family history of
psychiatric illness was suggestive of mood disorder (Depressive illness)
in the first-degree relative. On Mental Status Examination (MSE) the
findings revealed increased psychomotor activity, elated mood, high
distractibility, and subjective reporting of racing thoughts. The score
on Young’s Mania Rating Scale (YMRS) at the first visit was 18 points.
All the routine investigations were within normal limits including MRI
Brain. He was prescribed Tab. Risperidone 2mg H.S. and chemotherapy with
capecitabine were resumed in liaison with the oncology team. While on
capecitabine and risperidone, his manic symptoms started to resolve over
a week. The risperidone was further increased to 3 mg and the patient’s
manic symptoms remitted within the next week as evidenced by the drop in
the YMRS score from 18 to 6. The patient was discharged and followed up
on outpatient care.
The patient was followed up on monthly basis and was found to have
premorbid functioning with no psychopathology on MSE (YMRS score of 0).
He completed the scheduled chemotherapy cycles under the cover of Tab.
Risperidone which was subsequently reduced to 2mg at the end of one
month. Both capecitabine and risperidone were continued together to
prevent any recurrence of symptoms.
As per the institutional and international guidelines on
pharmacovigilance, the rare adverse Drug Reaction (ADR) was reported to
the ADR monitoring center in central India. The information was
registered using vigiflow and vigibase software under the unique ID for
the registered ADR as IN-IPC-30057221010.