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Axillary hidradenitis suppurativa successfully treated with infliximab in a Crohn's disease patient

Accident and Emergency department after a road traffic accident. He reported that, 2 days earlier, he had started to hear male voices talking about him in a derogatory manner. He also described visual hallucinations taking the form of strangers sitting in his room conversing with him. He was unaware that these experiences could be related to his recent steroid therapy, and he refused to leave his house. On the day of the accident, he started taking alcohol to combat the hallucinations. Some time later, he reported hearing a knock at his door and described seeing a group of unknown men on his doorstep commanding him to rob a nearby petrol station. He described being distracted by seeing the intruders follow him in a car and, as a consequence, he crashed into a disused railway line. Surprisingly, he escaped with relatively minor injuries. He was admitted to the hospital and continued to experience both complex visual and auditory hallucinations, constantly needing reassurance from nursing staff. There was no evidence of any mood disturbance, disorientation or alteration of consciousness. Psychiatric assessment established a diagnosis of steroid-induced psychosis. He was commenced on haloperidol 2.5 mg t.i.d., lorazepam 2 mg as required, and his steroids were reduced. He responded rapidly and was completely free of psychotic symptoms within a week. He was discharged on prednisolone 15 mg daily and had remained well at 1-month follow-up. This case illustrates the potentially serious nature of psychiatric symptoms arising from steroid therapy. There is some evidence of a dose-related effect but little information regarding other risk factors. In one study, psychiatric symptoms were recorded in 1.3% of patients receiving more than 40 mg of steroids, 4.6% of those receiving 40 – 80 mg daily, and 18.4% in patients on doses higher than 80 mg daily (3). However, reports also exist of adverse effects after exposure to very low doses, and there does not appear to be a correlation between dose and time of onset or type of disorder (4). Moreover, there is no evidence to suggest that past psychiatric history, previous steroid induced psychiatric disorder, or specific medical disorders help to identify individuals at risk (5). Clearly, identifying risk factors and measures to prevent steroid-related psychiatric disorders require further study. However, in the absence of clear clinical predictors, physicians need to be aware of the range of psychiatric disorders arising in the context of steroid use. We would strongly recommend that all patients treated with steroids, particularly at higher doses, are educated as to possible psychiatric symptoms associated with steroid use. Ideally, assessment of mental state including cognitive assessment should be carried out at baseline and repeated once the patient commences therapy. If there is evidence of emerging psychopathology, then a psychiatric consultation may be indicated. Information facilitating informed consent in the usage of these drugs might obviate the level of distress arising for patients developing psychiatric symptoms and avoid potentially fatal outcomes.