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\begin{document}

\title{Hyoscine butylbromide induced psychosis: A case report}



\author[1]{Nimesh Lageju}%
\author[1]{Durga Neupane}%
\author[1]{Lokesh Jaiswal}%
\author[2]{Upama Phuyal}%
\affil[1]{BP Koirala Institute of Health Sciences}%
\affil[2]{The University of Texas at Arlington}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
Hyoscine butylbromide induced pyschosis, though rare, should be
considered in a child presenting with deteriorating cognitive functions
and psychotic features acutely as evident in our case of a 9-year-old
child taking hyoscine for her non-specific abdominal pain.%
\end{abstract}%



\sloppy


\textbf{Hyoscine butylbromide induced psychosis: A case report}

Nimesh Lageju\textsuperscript{1}, Durga Neupane\textsuperscript{1},
Lokesh Shekher Jaiswal\textsuperscript{2}, Upama
Phuyal\textsuperscript{3}

\begin{enumerate}
\tightlist
\item
  MBBS, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
\item
  Department of Surgery (Division of CTVS), B.P. Koirala Institute of
  Health Sciences, Dharan, Nepal
\item
  The University of Texas at Arlington, TX, USA
\end{enumerate}

\textbf{Authors}

Nimesh Lageju

Email: nimesh.lageju@yahoo.com

ORCID iD

https://orcid.org/0000-0002-1411-5867

Durga Neupane

Email: neupanedurga26@gmail.com

ORCID iD

https://orcid.org/0000-0002-9736-9335

Lokesh Shekher Jaiswal

Email: lokesh\_shekher@yahoo.com

Upama Phuyal

Email: upamaphuyal2015@gmail.com

\textbf{Corresponding author}

Nimesh Lageju

Email: nimesh.lageju@yahoo.com

ORCID iD

https://orcid.org/0000-0002-1411-5867

\textbf{Key Clinical Message}

Through this case, we hope to communicate the notion that every
practitioner should be aware of common medicines with anticholinergic
effects, and drug-induced psychosis should be investigated in young
patients with acute behavioral abnormalities.



\textbf{Abstract}

Hyoscine butylbromide induced pyschosis, though rare, should be
considered in a child presenting with deteriorating cognitive functions
and psychotic features acutely as evident in our case of a 9-year-old
child taking hyoscine for her non-specific abdominal pain.

\textbf{Keywords:} Hyoscine butylbromide; psychosis; hallucination;
physostigmine\textbf{.}



\textbf{Introduction}

Hyoscine is a non-selective muscarinic acetylcholine receptor antagonist
that binds to a group of muscarinic receptors (M1-M5) that modulates the
release of acetylcholine or dopamine indirectly. M1-like muscarinic
receptors (M1, M3, M5) and M2-like muscarinic receptors (M2, M4)
activate and inhibit G-protein-mediated second messenger transduction,
respectively.\textsuperscript{1,2} Hyoscine blockade of the M2
muscarinic auto-receptor in the axon terminal is thought to raise
acetylcholine levels in the substantia nigra (SN) and ventral tegmental
area (VTA) midbrain areas, increasing striatal dopaminergic levels in
the mesopontine nuclei.\textsuperscript{3,4} Positive psychotic symptoms
like hyperactivity and stereotypy may result from such
activity.\textsuperscript{5,6} Inhibition of M4 subtype receptors, on
the other hand, has been linked to memory and attention
problems.\textsuperscript{1}

We report a case of hyoscine-induced psychosis in a 9-year-old female.
The psychosis began when the medicine was taken and faded once it was
stopped. After a few days of being off the medicine, the child was
perfectly fine.

\textbf{Case presentation}

A 9-year-old female was presented to the emergency room of our hospital
with complaints of exhibiting abnormal behaviors. The symptoms had
developed over the previous six hours. She complained of being dizzy and
experiencing a dry mouth. Intermittent hallucinations started. She
described her visions of ``her friends playing games.'' She heard ``her
mother's voice calling her.'' She also had a tactile hallucination in
which she felt something crawling on her back. She constantly attempted
to pick imaginary things from the floor.

Upon arrival at the emergency, the girl was hyperactive and was held
still by her uncle. She had a blood pressure of 110/70 mm of Hg, a heart
rate of 92 /min, a temperature of 98.2 F, respiratory rate of 20 /min.
Her mouth and skin were dry. Pupils were slightly dilated and reactive
to light. She was constantly agitated and restless. Her~cognitive
deficits were quite remarkable because she was unable to recognize
previously familiar people and was not oriented to place or time. There
were no focal neurological abnormalities found. There was no history of
head trauma, and no obvious injuries were discovered. A day prior, the
girl had visited OPD for complaints of abdominal pain for which hyoscine
butylbromide 20 mg was prescribed to be taken three times a day.

Laboratory results for hemoglobin, total leukocyte count, platelet
count, urine routine and microscopy, liver function test, renal function
test, and random blood sugar were within normal limits. The chest X-ray
was normal. Due to her bizarre behavior and suspicion of hyoscine
intoxication, she was admitted for further evaluation. A pediatrician
and a psychiatrist were consulted. The prescription of hyoscine was
stopped.

The evening after admission, the girl showed improvement in her symptoms
including her memory and hallucinations. She was no longer hyperactive
and began to become shy. After proper counseling to her relatives, she
was discharged. On follow-up, there was no recurrence of those symptoms
and she was completely recovered.

\textbf{Discussion}

This case exemplifies several issues that can arise when diagnosing
toxic psychosis caused by orally administered hyoscine. Hyoscine is
usually prescribed in adult patients for the treatment of abdominal pain
associated with cramps induced by gastrointestinal (GI) spasms. It is an
antimuscarinic medication that works similarly to atropine. It is made
from a belladonna alkaloid (Atropa belladonna, commonly known as deadly
nightshade). It antagonizes acetylcholine at muscarinic receptors at
therapeutic doses, but it can also antagonize nicotinic receptors at
high doses.\textsuperscript{7}

Confusion, hallucination, fatigue, short-term memory loss, difficulty
urinating, blurred vision, skin redness, and changes in heart rate are
all common complications or side effects of hyoscine
butylbromide.\textsuperscript{8} A person suffering from anticholinergic
intoxication can be described as ''red as a beet, hot as a hare, dry as
a bone, blind as a bat, mad as a hatter.'' ~This is a representation of
a patient's flushed skin, hyperthermia, dry mucous membranes, blurred
vision, and confusion or delirium.\textsuperscript{9} Most cases of
hyoscine intoxication can be treated by stopping the offending drug and
providing supportive care to lower the patient's fever, keep them cool,
and keep them hydrated. Benzodiazepines can be used to reduce agitation
and restlessness in patients. Patients who have toxic psychosis for up
to 48 hours and are a danger to themselves and others may need to be
admitted to the hospital for close monitoring and
management.\textsuperscript{10} In our case, however, the patient
recovered completely after the drug was stopped for 24 hours. Due to
laboratory limitations, the serum level of hyoscine was not measured.

Poonai et al. randomly assigned children aged 8--17 years with
nonspecific colicky abdomen pain who reported to the pediatric emergency
department at London Health Sciences Centre in London, Ontario, to
receive hyoscine butyl bromide, 10 mg orally, or acetaminophen, 15 mg/kg
orally (maximum 975 mg). In this study, hyoscine butyl bromide did not
outperform acetaminophen. 32/116 (27.6 percent) of individuals in the
hyoscine butylbromide group experienced adverse reactions in the
emergency department. Nausea, vomiting, dizziness, and photosensitivity
were common adverse effects. There were no significant side
effects.\textsuperscript{11}

Anticholinergic-induced agitation, delirium, and hallucinations are
treated with physostigmine, an acetylcholinesterase
inhibitor.\textsuperscript{12,13} While the patient is being observed, a
test dose of physostigmine, usually 0.5 or 1 mg, can be given
intramuscularly, subcutaneously, or
intravenously.\textsuperscript{14,15} Arrhythmias or hypotension caused
by the physostigmine-induced cholinergic crisis should be monitored
closely. Before prescribing physostigmine, it's important to rule out
any potential contraindications like renal hypertension,
hyperthyroidism, diabetes, or coronary artery disease.

\textbf{Conclusion}

The safety of hyoscine in children has not yet been determined, and the
effects of this medicine may be cumulative; so, the drug's usage in
pediatric patients is not suggested.\textsuperscript{16} The take-home
lesson from this case is that clinical practitioners should be aware of
common drugs having anticholinergic effects and that drug-induced
psychosis should be evaluated in young patients exhibiting acute
behavioral abnormalities.

\textbf{Ethical Approval}

Consent from the patient's party was enough.

\textbf{Consent for Publication}

Since our patient was a minor, written informed consent was obtained
from the patient's party.

\textbf{Financial support and sponsorship}

None

\textbf{Conflict of interest}

None

\textbf{Author contribution}

NL, DN, LSJ and UP wrote the initial draft of the manuscript. NL and DN
edited the draft and reshaped it into this manuscript. The final version
of the manuscript was approved by all authors and agree to be
responsible for all aspects of the work.

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