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Antimicrob Agents Chemother. While EEG is typically normal after both asymptomatic administration of mefloquine195 and after some cases of mefloquine intoxication,41,101 the presence of deep epileptiform or other abnormal activity,20,84,107,137,186,196,197 in the absence of a clinical history of limbic seizure disorder, strongly supports the diagnosis of mefloquine intoxication or neurotoxicity. One week later, he was hospitalized after developing frank psychosis with psychomotor agitation and paranoid delusions. Gap junction channels, composed of proteins called connexins, are involved in coordinated synchronization of neuronal activity, particularly of inhibitory interneurons121 found throughout the limbic system.122 At concentrations consistent with limbic accumulation, mefloquine has been demonstrated to inhibit electrical coupling of neurons with effects on limbic inhibition123,124 and resultant mesolimbic dopaminergic tone.125,126 In dysregulating limbic inhibition, this mechanism may mimic to some degree what is also seen with intoxication by phencyclidine (PCP),127 ketamine,128 and other dissociative amnestics and hallucinogens,129,,131 whose effects share many schizomimetic properties in common with those of mefloquine intoxication and limbic encephalitis. The site is secure. government site. Drug information provided by: Merative, Micromedex Along with its needed effects, a medicine may cause some unwanted effects. Epub 2020 Jan 24. Neuropsychiatric adverse events after therapeutic doses of mefloquine have been difficult to study mainly because malaria itself often causes CNS symptoms, and current practices in endemic regions require mefloquine/artesunate combination therapy due to increasing mefloquine resistance [15]. It is tempting to speculate that in some cases, this presentation may reflect the clinical course of an underlying limbic status epilepticus114 or limbic seizure132,,134 kindled by the drug.135 In this regard, it is reasonable to speculate further that simultaneous use of alcohol or certain other drugs together with mefloquine could lower limbic seizure threshold or cause a further dysregulation of limbic inhibitory interneurons,125 contributing to a risk of sudden potentiation. Hood JE, Jenkins JW, Milatovic D, Rongzhu L, Aschner M. Neurotoxicology. Epub 2011 May 14. Dr. Nevin has been retained as consultant and expert witness in legal cases involving claims of antimalarial toxicity. Along with atovaquone/proguanil and doxycycline, mefloquine is currently recommended as malaria prophylaxis for travel in areas with chloroquine-resistant Plasmodium falciparum by health authorities in the United States, the United Kingdom, and Canada [2,3]. FDA advise-ERR: mefloquinenot the same as Malarone; zoster vaccine is not for the immunosuppressed; TXA mistaken as tenecteplase; guidelines for adult IV push medications. Milatovic D, Jenkins JW, Hood JE, Yu Y, Rongzhu L, Aschner M. Neurotoxicology. The GSH content of control (a) and transfected (b) primary rat cortical neurons was determined after 24-hour incubations with graded concentrations of mefloquine using monochlorobimane, a fluorescent probe for GSH. WebMefloquine may enhance the QTc prolonging effect of high risk QTc prolonging agents. In addition, both military and civilian users of mefloquine have advanced claims of harm and damages in civil courts,55,56,178 but the outcomes of many of these cases have not been made publicly available. Mefloquine is highly lipophilic116 and may accumulate in the limbic system117 relative to other areas of the brain,118,119 where it acts to disrupt a form of direct intercellular electrical communication120 that is essential for coordinated inhibitory control. Because of its lipophilicity116 and its recycling within the enterohepatic circulation, mefloquine may be excreted unchanged in the feces12 and also may be found in the gastric juices and bile. :5 case reports (in French), Effects of mefloquine alone and with alcohol on psychomotor and driving performance, The limbic system conception and its historical evolution, Hepatic encephalopathy: from pathophysiology to treatment, Proposition: limbic encephalitis may represent limbic status epilepticusa review of clinical and EEG characteristics, Drug interactions and pharmacogenetic reactions are the basis for chloroquine and mefloquine-induced psychosis, The antimalarial drug mefloquine binds to membrane phospholipids, Stereoselective passage of mefloquine through the blood-brain barrier in the rat, Central nervous system exposure of next generation quinoline methanols is reduced relative to mefloquine after intravenous dosing in mice, Mefloquine distribution in postmortem cases, Potent block of Cx36 and Cx50 gap junction channels by mefloquine, Electrical synapses in the mammalian brain, The role of gap junctions in the brain in health and disease, Connexin-36 gap junctions mediate electrical coupling between ventral tegmental area GABA neurons, Brain stimulation reward is integrated by a network of electrically coupled GABA neurons, The role of connexin-36 gap junctions in alcohol intoxication and consumption, Mefloquine effects on ventral tegmental area dopamine and GABA neuron inhibition: a physiologic role for connexin-36 gap junctions, Chloroquine psychosis masquerading as PCP: a case report, The N-methyl-D-aspartate antagonists phencyclidine, ketamine and dizocilpine as both behavioral and anatomical models of the dementias, Drugs of abuse and the elicitation of human aggressive behavior, Suicide by hanging under the influence of ketamine and ethanol, The sensed presence: an epileptic aura with religious overtones, Numinous-like auras and spirituality in persons with partial seizures, Phenomenology of hallucinations, illusions, and delusions as part of seizure semiology, Gamma-aminobutyric acid and mefloquine-induced seizures in mice, Cerebral spasm during malaria prophylaxis with mefloquine (in German), Neuropsychiatric problems in 2,500 long-term young travelers to the tropics, Energy deprivation transiently enhances rhythmic inhibitory events in the CA3 hippocampal network in vitro, Nonspecific effects of the gap junction blocker mefloquine on fast hippocampal network oscillations in the adult rat in vitro, Electrical synapses control hippocampal contributions to fear learning and memory, Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies, Limbic encephalitis presenting with seizures, anterograde amnesia, and psychosis in a patient seven weeks status post immature ovarian teratoma removal, Hypersexuality or altered sexual preference following brain injury, Multifocal myoclonus associated with mefloquine chemoprophylaxis, Suspected convulsive side-effect of mefloquine (Lariam) (in German), Anti-malaria drug mefloquine induces motor learning deficits in humans, Anti-Huassociated paraneoplastic encephalomyelitis/sensory neuronopathy: a clinical study of 71 patients, Acute nonparaneoplastic limbic encephalitis in childhood: a case series in Japan, The brain circuitry underlying the temporal evolution of nausea in humans, Mefloquine prophylaxis and hearing, postural control, and vestibular functions, Peripheral polyneuropathy and mefloquine prophylaxis, Mefloquine induces dose-related neurological effects in a rat model, Severe orthostatic hypotension during treatment of falciparum malaria, Postural orthostatic tachycardia syndrome: a case report of palpitations and dizziness following prophylactic mefloquine use, Sequential treatment with quinine and mefloquine or quinine and pyrimethamine-sulfadoxine for falciparum malaria, Central anticholinergic syndrome with the antimalarial drug mefloquine, Limbic encephalitis: a cause of temporal lobe epilepsy with onset in adult life, Animal model of schizophrenia: dysfunction of NMDA receptor-signaling in mice following withdrawal from repeated administration of phencyclidine, Delayed sclerosis, neuroprotection, and limbic epileptogenesis after status epilepticus in the rat, The acute neurotoxicity of mefloquine may be mediated through a disruption of calcium homeostasis and ER function in vitro, The antimalarial potential of 4-quinolinecarbinolamines may be limited due to neurotoxicity and cross-resistance in mefloquine-resistant Plasmodium falciparum strains, Mefloquine induces oxidative stress and neurodegeneration in primary rat cortical neurons, The effect of certain quinoline compounds upon the nervous system of monkeys, Effects of pamaquine on the central nervous system, Neurotoxicity of the 8-aminoquinolines; reactions of various experimental animals to plasmocid, The selective effect of drugs upon nuclei of the oculogyric system, Plasmocid encephalopathy in the rhesus monkey: a study of selective vulnerability, Canadian Department of National Defense (DND), Report of the somalia commission of inquiry: the mefloquine issue, Minister of Public Works and Government Services, Exclusive: Army surrenders to coward GI, U.S. army base tries to stop soldier suicides, Toxic cocktail: army struggles with mental-health care, Malaria chemoprophylaxis: in war and peace, Prevention of malaria in long-term travelers, Tolerability of malaria chemoprophylaxis in non-immune travellers to sub-Saharan Africa: multicentre, randomised, double blind, four arm study, Malaria chemoprophylaxis: strategies for risk groups, Divided-dose kinetics of mefloquine in man, Kinetic studies of mefloquine and of one of its metabolites, Ro 21-5104, in the dog and in man, Mefloquine prophylaxis and neurotoxicity: report of a case (in French), Acute brain syndrome after mefloquine treatment (in German), Cerebral uptake of mefloquine enantiomers in fatal cerebral malaria, Serious adverse events of mefloquine in relation to blood level and gender, Mefloquine tolerability during chemoprophylaxis: focus on adverse event assessments, stereochemistry and compliance, Pharmacokinetic considerations in the repositioning of mefloquine for treatment of progressive multifocal leukoencephalopathy, Polymorphism at the MDR1 locus as a cause of mefloquine-induced psychosis (in Hebrew), MDR1 gene polymorphisms are associated with neuropsychiatric adverse effects of mefloquine, Cerebral uptake of mefloquine enantiomers with and without the P-gp inhibitor elacridar (GF1210918) in mice, Modulation of the function of human MDR1 P-glycoprotein by the antimalarial drug mefloquine. The case presented here supports a dose-dependent effect of mefloquine neurotoxicity, as Mr. A developed profound anxiety and subsequent paranoid psychosis only after his dose was escalated from 250 mg to a one-time dose of 1250 mg. To date, the effects of mefloquine on the CNS remain unclear, given the limited literature on this topic. Interestingly, serious adverse events do not seem to correlate with mefloquine levels in the blood [23], implying that the risk of developing neuropsychiatric symptoms may be related to an individual's threshold for mefloquine rather than absolute mefloquine blood levels. Similarly, consultation with neurology should be considered to rule out closely related conditions such as limbic encephalitis or prior clinical history of limbic seizure, which in certain cases may also confound the diagnosis of mefloquine intoxication. 2004 Jul;48(7):2624-32. doi: 10.1128/AAC.48.7.2624-2632.2004. Intramuscular haloperidol was administered to treat his acute psychotic agitation. The UK is the first country to allow OTC access to Sanofi's tadalafil-based erectile dysfunction drug Cialis following a successful switch. http://creativecommons.org/licenses/by/2.0. The https:// ensures that you are connecting to the The site is secure. Price RN, Uhlemann AC, Brockman A, McGready R, Ashley E, Phaipun L, Patel R, Laing K, Looareesuwan S, White NJ, et al. An official website of the United States government. Public Health Mefloquine (Lariam) Malaria is a serious infectious disease transmitted by mosquitoes. In this section, the putative pathophysiology of mefloquine intoxication is described in further detail following a discussion of its typical clinical presentation. Then, in 2013, See this image and copyright information in PMC. Mr. A was diagnosed with hypertension and, incidentally, with Type II diabetes mellitus. You may report side effects to the FDA at 1-800-FDA-1088. He DESCRIPTION Mefloquine Hydrochloride Tablets, USP is an antimalarial agent available as 250 mg tablets of mefloquine hydrochloride, USP (equivalent to 228 mg of the free base) for oral CLINICAL PHARMACOLOGY PMC [1] Researchers have identified cases of mefloquine poisoning causing a central, rather than a peripheral vertigo, consistent with dysfunction in the brainstem vestibular nuclei. Careers. The forensic application of a claim of mefloquine intoxication begins with establishing plausible evidence of exposure. Exposure to the drug has been associated with acts of violence and suicide. Portions of this document last updated: May 01, 2023. J Parasitol Res. Data represent mean SEM (bars) values from 3 independent experiments with n 24. Mefloquine may also be occasionally detected in the cerebrospinal fluid,21,185 although cerebrospinal fluid concentrations correlate poorly with concentrations in other compartments,21,24,186 and cerebrospinal fluid186 and serum concentrations themselves correlate poorly with brain accumulation119,187 and with propensity to psychiatric effects.24,188,189 Owing to the marked heterogeneity of mefloquine neuropharmacokinetics,190 which remain poorly understood but are most likely subject to multifactorial genetic191,192 and pharmacologic influences,193,194 any demonstration of mefloquine or its metabolite in any compartment of body fluid should be considered sufficient evidence of exposure and hence of potential brain accumulation and plausible intoxication. Federal government websites often end in .gov or .mil. 2022 Oct 29;17:100469. doi: 10.1016/j.mtbio.2022.100469. 2004 Jul;48(7):2624-32. doi: 10.1128/AAC.48.7.2624-2632.2004. Work-up for pheochromocytoma, porphyria, and heavy metal toxicity was negative. 2021 Dec;464:152995. doi: 10.1016/j.tox.2021.152995. Review of the mechanism underlying mefloquine-induced neurotoxicity. His vital signs remained stable. Neurotoxicology. The antimalarial potential of 4-quinolinecarbinolamines may be limited due to neurotoxicity and cross-resistance in mefloquine-resistant Plasmodium falciparum strains. eCollection 2022 Dec 15. The pathophysiological insights presented in this review will aid the forensic psychiatrist in conducting an evaluation and in securing appropriate consultation in support of this goal. MeSH His neuropsychiatric symptoms appeared the next day, concomitant with the presumed peak of mefloquine, which reaches maximum concentration in the blood within 24 hours of an oral dose [1]. WebCialis Together 10mg Tablets - Tadalafil - 4 Tablets. Disclaimer. The risk of severe depression, psychosis or panic attacks with prophylactic antimalarials. The site is secure. Copyright 2023 by The American Academy of Psychiatry and the Law. Epub 2010 May 24. He then went to the emergency department of an outside hospital and was admitted for a hypertensive emergency. Curses, madness, and mefloquine. Mayo Clinic on Incontinence - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, blistering, loosening, peeling, or redness of the skin, hallucinations (seeing, hearing, or feeling things that are not there), irregular, pounding, slow, or fast heartbeat or pulse, sores, ulcers, or white spots in the mouth or on the lips, swelling of the ankles, feet, or lower legs, continuing ringing or buzzing or other unexplained noise in the ears, feeling of constant movement of self or surroundings, muscle spasm or jerking of all extremities. Lee SJ, Ter Kuile FO, Price RN, Luxemburger C, Nosten F. PLoS One. Careers. Reports of multifocal myoclonus145,146 and deficits in motor speed38,39,40 and motor learning147 are suggestive of further involvement of the basal ganglia and inferior olive. Alprazolam as a neuroleptic adjunct in the emergency treatment of schizophrenia. Ball P, Mandell L, Niki Y, Tillotson G. Comparative tolerability of the newer fluoroquinolone antibacterials. This report describes an acute exacerbation of neuropsychiatric symptoms after an unwarranted therapeutic dose (1250 mg) of mefloquine in a 37-year-old male previously on a once-a-week prophylactic regimen. Mefloquine-induced psychosis. Dow GS, Hudson TH, Vahey M, Koenig ML. Clipboard, Search History, and several other advanced features are temporarily unavailable. The common symptoms of insomnia and abnormal dreaming affect > 10% of users. In addition to a dose-dependent progression, symptoms of mefloquine intoxication may exhibit a waxing and waning presentation. This information is anticipated to be useful when forensic psychiatrists are asked to consult on cases involving military personnel and veterans, civilian travelers, and employees on overseas assignment who claim legal implications from their exposure to the drug. The patient's anxiety culminated into a panic episode with profound sympathetic activation. He was held overnight for observation and discharged the following morning on metoprolol 100 mg qd, lisinopril 10 mg qd, rosiglitazone 1 mg bid, and metformin 500 mg bid, and zolpidem 10 mg qhs. Proposals for articles are encouraged and can be sent to moc.mocdemeniltnorf@carpdef. As a result of the drug's accumulation in tissue,12 it also may remain readily detectable at low concentrations in serum.183 The various hydrophilic metabolites of mefloquine182 may also be found at low concentrations in urine, bile, feces, and serum.12 Testing for such compounds is readily available at analytic reference laboratories using established techniques.12,184. One patient developed confusion, agitation, ataxia, dizziness, speech difficulties, and high-frequency hearing loss after taking 15 250 mg of mefloquine over two months. They also may contribute to lasting and significant changes in personality, mood, cognition, thought, sleep, and behavior.6. Psychiatric effects of malaria and anti-malarial drugs: historical and modern perspectives. WebToxicity. The liquid form works best if taken without other fluids. Dosage (Posology) and method of administration Results of these and subsequent trials have since demonstrated that the incidence of specific neuropsychiatric symptoms including nightmares, anxiety, and psychosis during prophylactic use are each at least 100 times more common28,30,31 than has been previously reported.32,,35, More recent reports of suicide31,36,37 and suicidal ideation,38,,47 and studies linking the drug to acts of violence48 have raised additional safety concerns.49,50 As public awareness of the potential dangers of mefloquine have grown,51,,54 and civil litigation related to the drug has increased,55,56 mefloquine has lost significant market share in the United States57 in favor of safer and better tolerated antimalarial medications.28 Today, mefloquine is no longer considered the drug of choice, either in therapy or in chemoprophylaxis of malaria.58 Roche recently withdrew Lariam from the U.S. market, although generic forms remain widely available.59, Use of mefloquine had previously been encouraged among United States overseas diplomatic staff60 and Peace Corps volunteers.8,25 Mandatory use of the drug was also broadly directed among deployed U.S. military service members.61,62 Recently, growing awareness of the drug's inappropriate prescribing33,34,63 to service members with mental health contraindications,39,62,64 including those with a history of posttraumatic stress disorder and traumatic brain injury,34,63 and poor documentation of its prescribing64 has significantly diminished the utility of mefloquine in deployed settings.65 As a result, today, mefloquine is considered the drug of last resort by U.S. military policy,66,67 to be used only when doxycycline and the combination drug atovaquone/proguanil (Malarone) cannot be used.58,65,68,69. While the unique presentation of mefloquine intoxication has been clinically well characterized in the present review, where exposure to mefloquine has been established, it is appropriate for the forensic psychiatrist to consider the diagnosis only when other psychiatric, medical, and substance-induced etiologies can be reasonably excluded as more probable causes. Similarly, as the resolution of MRI improves to encompass the visualization of submillimeter lesions, conventional imaging may also hold promise. For years, Canadian soldiers were told to ignore such symptoms, but left unchecked, mefloquine poisoning can cause permanent injury to the brain and brainstem, resulting in lasting symptoms including tinnitus, dizziness, vertigo, paresthesias, visual disturbances, nightmares, insomnia, sleep apnea, anxiety, agoraphobia, paranoia, cognitive Taylor and White reviewed several studies assessing the effect of mefloquine on psychomotor performance and fine motor skills and concluded that mefloquine did not significantly interfere with higher mental function despite causing adverse effects such as sleep disturbances and changes in affect [20]. Because the drug is associated with an increased risk of violence48 and psychiatric symptoms, users of mefloquine may be likely to be encountered in the civil or criminal legal systems. It is important that physicians advise patients taking mefloquine and their relatives to recognize specific symptoms, especially when they are accompanied by abrupt but subtle changes in behaviour. It is available in the United States by prescription only. According to the current U.S. mefloquine package insert,70 psychiatric symptoms associated with prophylactic mefloquine use include abnormal dreams, anxiety, paranoia, agitation, confusion, memory impairment, and hallucinations. Mefloquine, a 4-quinoline methanol structurally related to quinine, has a long elimination half-life of 14 to 41 days [1], which allows for once-a-week dosing and makes it a popular choice as malaria prophylaxis for travelers to malaria endemic areas. However, several epidemiological studies have raised concerns on the safety of mefloquine as prophylaxis for malaria. Bethesda, MD 20894, Web Policies Mefloquine intoxication has not yet been successfully advanced in legal proceedings as a defense or as a mitigating factor, but it appears likely that it eventually will be. Adverse effects of mefloquine for the treatment of uncomplicated malaria in Thailand: A pooled analysis of 19, 850 individual patients. His wife, fearful of his increasing agitation and paranoia, finally coaxed Mr. A into going to the emergency department at a university-affiliated hospital. Rufener R, Ritler D, Zielinski J, Dick L, da Silva ET, da Silva Araujo A, Joekel DE, Czock D, Goepfert C, Moraes AM, de Souza MVN, Mller J, Mevissen M, Hemphill A, Lundstrm-Stadelmann B. Int J Parasitol Drugs Drug Resist. Approved as a pharmacy medicine, Sanofi will launch Cialis Together in the second half of the year. Federal government websites often end in .gov or .mil. Thank you for your interest in recommending The Journal of the American Academy of Psychiatry and the Law site. the contents by NLM or the National Institutes of Health. 2020 Mar;77:169-180. doi: 10.1016/j.neuro.2020.01.006. Blood glucose was mildly elevated at 146 mg/dL. Taylor WR, White NJ. The current recommended prophylactic dose is 250 mg once a week for adults. Hughes C, Tucker R, Bannister B, Bradley DJ. Bethesda, MD 20894, Web Policies Neurotoxicology. Nevin RL, Ritchie E. The mefloquine intoxication syndrome: a significant potential confounder in the diagnosis and management of PTSD and other chronic deployment-related neuropsychiatric disorders. His claims were incongruent with his behaviour, as he was even more inquisitive than previously, again challenging the staff on their medical knowledge and questioning the rationale behind his medical treatment. [2,3] Health Canada has warned that mefloquine can cause other serious side effects, including mental problems, said Dr. Nevin. The case demonstrates the time course of mefloquine-induced neuropsychiatric toxicity, revisits the dose dependent nature of such adverse events, and reviews the current literature. However, the increased use of mefloquine over the past decade has resulted in reports of rare, but severe, neuropsychiatric adverse reactions, such as anxiety, depression, hallucinations and psychosis. Forensic and Ethical Issues in Military Behavioral Health. If prophylactic exposure to the drug has been established, the clinician should confirm the presence of neuropsychiatric symptoms during the exposure. Unauthorized use of these marks is strictly prohibited. While characteristically affecting limbic centers, the effects of mefloquine intoxication may extend beyond the limbic system. Therefore, recognition of specific neuropsychiatric symptoms and behavioural changes in a patient taking mefloquine may prompt physicians to more carefully assess the patient and intervene if necessary before severe psychosis develops. On a biochemical level, there is evidence that mefloquine may disrupt calcium homeostasis and induce a stress response in rat neurons in vitro [24]. Although several hypotheses have been proposed for the mechanisms that mediate mefloquine-induced brain damage, they are not fully understood, necessitating additional studies in the future. This article may discuss unlabeled or investigational use of certain drugs. He denied fever, chills, night sweats, or nausea. Prior to developing overt psychosis, Mr. A had initially experienced vertigo and insomnia for several days followed by a full week of escalating anxiety and subtle alterations in behaviour. He demonstrated paranoid behaviour and was highly suspicious of the staff, frequently checking identification badges and quizzing the staff in order to verify their background and knowledge. As evidence is increasingly clear that use of mefloquine is associated with a risk of long-term injury and harm, as well as death of self or others, so long as the drug remains licensed for use, physicians who continue to prescribe it must exercise caution to minimize potential liability. For treatment of malaria, mefloquine was used widely until better-tolerated drugs became available, beginning in the early 2000s, although some use of mefloquine in the military continues to this day. Please enable it to take advantage of the complete set of features! Smithuis FM, van Woensel JB, Nordlander E, Vantha WS, ter Kuile FO. This article is part of a regular column focused on mental health care and traumatic brain injury, edited and occasionally authored by COL (Ret) Elspeth Cameron Ritchie, MD, MPH. When used for prophylaxis in military settings, the drug was often dispensed informally without documentation, sometimes including directly observed therapy under command direction.1,2 Therefore, even in the absence of prescribing documentation, a veteran who endorses a consistent history of malaria prophylaxis with mefloquine should be considered as having evidence of exposure.2, Exposure to mefloquine is unlikely if the veteran reports taking a daily antimalarial medicationmore likely it was doxycycline or atovaquone/proguanil (marketed as Malarone). Physicians must explicitly caution patients not to self-medicate with a therapeutic course of mefloquine when a malaria diagnosis has not been confirmed. The presence of comorbid conditions may create a challenge for the forensic psychiatrist in evaluating a claim of mefloquine intoxication. The psychiatric effects of the drug may be featured in future forensic evaluations, and thus forensic psychiatrists may be called to comment on the drug's effects. As the boxed warning indicates, certain psychiatric symptoms that occur with mefloquine use may become chronic and may confound psychiatric diagnosis. This section, the clinician should confirm the presence of neuropsychiatric symptoms during the exposure the QTc effect! Tillotson G. Comparative tolerability of the complete set of features, night sweats, or.. He was hospitalized after developing frank psychosis with psychomotor agitation and paranoid delusions 250 mg once a for. ):2624-32. doi: 10.1128/AAC.48.7.2624-2632.2004 please enable it to take advantage of the newer fluoroquinolone antibacterials similarly as... Mefloquine use may become chronic and may confound psychiatric diagnosis speed38,39,40 and motor learning147 are suggestive of involvement. 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