C a rt a a o E d ito r : K r e m s n e r P G , Z o tte r G M t B a c h A/, G r a n in g e r IV. A c a se o f tr a n si e n te o r g a n ic b ra in s y n d r o m e d u r in g q u in in e tre a tm e n t. R e v is ta d a S o c ie d a d e B ra s ile ir a d e M e d ic in a T ro p ic a l 2 2 (1 ): S 3, j a n - m a r , 1 989.
CARTA AO EDITOR
A CASE OF TR A N SIE N T O RGANIC BRAIN SYNDROM E
D U R IN G Q U IN IN E TREATM ENT
Quinine has becom e again the mainstay in treatment o f multidrugresistant falciparum malaria in the eighties. During quinine treatment minor side-effects frequently occur whereas serious side-side-effects such as irreversible deafness and amblyopia are rare. U sing normal or low doses of quinine a syndrome termed as cinchonism is com monly observed. Mild forms consist o f tinnitus, headache, nausea and visual and auditory disturbances. Here we describe a case o f transient organic brain syndrome which occurred during quinine treatment.
In Rio Branco, State o f A cre, Brazil, a 24 year old woman suffering from falciparum malaria was given oral quinine treatment consisting o f 500 mg quinine sulfate three times a day. From the third day o f therapy, the patient developed headache, blurred vision, vertigo, tinnitus and impaired hearing. Owing to misinstruction the patient took a daily dosage of 1.5 g quinine sulfate continuously for 16 days, even though symptoms o f apathy and disorientation appeared. On day 16 the patient was admitted to the Ministry o f Health’s outpatient clinic. A thick blood smear was negative, liver and spleen were of normal size, axillary temperature was 37.0°C and the patient was not pregnant During examination the patient was generally awake but sometimes with reduced clarity o f awareness o f the environment. Often she had difficulties in shifting, focusing and sustaining attention. Her speech was limited and sparse, her thinking often incoherent without the usual direction towards a goal. Both short-term and long-term memory functions were severely impaired. The patient was disorientated with respect to time, place and her own identity. Her capacity o f judgement was altered accompanied by an increased suggestibility. Affect,
mood and subjective wellbeing seemed to be unchan ged. Psychomotor activity was slightly decreased without any signs o f anxiety or suspicion. On the day o f admission quinine medication was stopped. D aily observation revealed a continuous reduction o f symptoms during a seven day period. Only a retro grade amnesia remained. Severe neuropsychiatric states are infrequent side effects o f cinchona alkaloids and related compounds. However, although mefloquine had not yet been widely used, an acute brain syndrome after mefloquine intake is reported1.
Furthermore a quinidine induced delirium has been described2. T o our knowledge this is the first report o f a transient organic brain syndrome occuring during quinine medication. For us this syndrome was considered to be caused by quinine for the following reasons:
1. Lack o f psychiatric disorders in the patient's history and her family’s history.
2. D evelopm ent o f clinical features during quinine intake.
3. Cessation o f symptoms after discontinuation o f the treatment which corresponded to quinine's terminal
half life.
4. N o evidence o f further psychiatric disorders during six months o f follow up examinations.
R E F E R E N C E S
1. Harinasuta T, Bunnag D, Wemsdorfer WH. A phase II clinical trial of mefloquine in patients with chloroquine - resistant falciparum malaria in Thailand. Bulletin of the World Health Organization 61:299-305, 1983. 2. Summers W K, Allen RE, Pitts F N Jr. Does physios-
tigmine reverse quinidine delirium? W estern Journal of Medicine 135:411-414, 1981.
Address: Dr. Peter G. Kremsner. Landesinstitut für Tro penmedizin Berlin, Königin Elisabeth Strasse 32 - D-1000 Berlin 19.
Recebido para publicação em 10/2/89.
Peter G. Kremsner, Gertraud M. Zotter Landesinstitut für Tropenmedizin Berlin, W est Germany
Michael Bach, Wolfgang Graninger Universitätsklink für Chemotherapie Wien, Austria
