Case Report A case of manic episode during treatment with 5-fluorouracil, epirubicin and cyclophosphamide for breast cancer Isabella Pacchiarotti, M.D. a,c, ⁎ , Lorenzo Mazzarini, M.D. a , Patrizia Pellegrini, M.D. b , Viola Venturelli, M.D. b , Gabriele Sani, M.D. a , José Sánchez-Moreno, Ph.D. c , Iginia Mancinelli, M.D. a , Roberto Tatarelli, M.D. a , Giorgio D. Kotzalidis, M.D. a , Paolo Girardi, M.D. a a Unit of Psychiatry, Department of Neurosciences, Sant'Andrea Hospital, 2nd Medical School, Sapienza University, 00189 Rome, Italy b Department of Oncology, Sant'Andrea Hospital, 2nd Medical School, Sapienza University, 00189 Rome, Italy c Bipolar Disorder Program, Institute of Neuroscience, Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain Received 12 February 2007; accepted 30 April 2007 Abstract A 41-year-old woman with breast cancer developed a manic episode while being treated with a 5-fluorouracil–epirubicin– cyclophosphamide combination (most likely caused by the first drug). Chemotherapy was discontinued, and antipsychotic treatment with haloperidol and olanzapine was instituted. She recovered after 10 days. Normal computerized tomography (CT) scans and neurological examinations were consistent with the absence of neurological symptoms on physical exam. © 2007 Elsevier Inc. All rights reserved. Keywords: 5-Fluorouracil; Epirubicin; Cyclophosphamide; Manic episode; Drug-induced; Leukoencephalopathy 1. Introduction The rationale for adjuvant chemotherapy given after local treatment of primary breast carcinoma is to eradicate possible occult metastases that would otherwise become fatal. The central nervous system is more resistant than other bodily systems to chemotherapy- induced toxicity due to the low proliferation rate of its cells and to the low permeability of most chemother- apeutics across the blood–brain barrier. However, some neurological complications (metabolic encephalopathy, delirium-like symptoms with confusion and disorientation, hallucinations and personality changes) have been described with the use of ifosfamide [1,2] and different ones with 5-fluorouracil (5-FU). 5-Fluorouracil has been used in standard chemotherapy regimens for breast cancer for several years. A few reports on 5-FU-induced neurological complications have been pub- lished, including organic mental disorder [3], dementia [4] and akinetic mutism associated with white matter hypoden- sity on brain computed tomography (CT) [5]. Secondary mania may account for 1–2% of cases in psychiatric consultation services [6,7]. In the few cases describing the onset of mood symptoms to chemotherapeutic agents, all have reported manic episodes induced by ifosfamide only [8,9]. We report on a woman presenting with reversible acute manic episode after receiving adjuvant chemotherapy [5-fluorouracil, epirubicin, cyclophospha- mide (FEC)] for breast cancer. 2. Case report In July 2006, a 41-year-old premenopausal woman underwent bilateral mammography screening. This revealed a right breast upper quadrant suspect mass which was subsequently confirmed by ultrasound to be malignant. General Hospital Psychiatry 29 (2007) 461 – 463 ⁎ Corresponding author. Sant'Andrea Hospital, 2nd Medical School, Sapienza University, 00189 Rome, Italy. Tel.: +39 0633775951; fax: +39 0633775342. E-mail address: isabella.pacchiarotti@uniroma1.it (I. Pacchiarotti). 0163-8343/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2007.04.007