Mania and Tramadol-Fluoxetine Combination

Ms. A was a 72-year-old woman who had been treated with fluoxetine, 20 mg/day, for the last 10 years. She had had no cognitive deficits, had never been hospitalized, and had had only one previous major depressive episode, occurring 10 years before. She had been taking acetaminophen for the last year for articular pain. She was planning to take a trip, so her doctor prescribed tramadol to relieve the pain. After 18 days of taking tramadol, 150 mg/day, and fluoxetine, 20 mg/day, Ms. A began to feel nervous, had a temperature of 37.2°C, piloerection, and muscular contractions.

She stopped taking tramadol, and her physical symptoms disappeared by day 21. Nevertheless, she was agitated, euphoric, and hyperactive, slept less than 3 hours a day, and demonstrated rapid speech and paranoid ideation. She was conscious and oriented at all times. Ms. A was hospitalized for 3 days and stopped taking fluoxetine; haloperidol treatment was initiated at 5 mg/day. The results of a physical examination were normal. After discharge, her symptoms continued, so by day 31 she was hospitalized again. She then began treatment with olanzapine, 10 mg/day. Two weeks later she was euthymic and was discharged from the hospital while taking olanzapine, 10 mg/day.