CHLOROQUINE INDUCED VISUAL HALLUCINATIONS ON EYE CLOSURE A CASE REPORT
DR. PFIZER .N. *
DR. PRAVEENLAL. M.D. DIP. NB **
DR. A. RAMACHANDRAN. M. D. ***
DR.K. KRISHNANKUTTY M.D. ****

INDRODUCTION
Awareness of medication induced behavioural changes among non- psychiatric patients are expending as well as the number of drug related hospital admission are increasing. (SHADER - 1972)). Use of chloroquin is on an increase in India due to recant increase in the incidence of Malaria cases. Chloroquine induced psychiatric side effects (REAGEN 1985, GOOD AND SHADER 1977, BHATIA 19910 are not uncommon. A case of chloroquine induced psychosis is reported here due to paucity of similar reports from Kerala.

CASE REPORT
Mr.B, 40 year old Christian mala, was referred from the infectious disease of medical College Trivandrum with complaints of behavioural oddities of one day duration.
Following a diagnosis of malaria 5 days back, on the basis of blood smear report, he was started on a six day chloroquine and primaquine regime, totaling to about chloroquine 2gms and primaquine 7.5gms. His fever subsided on the 2nd day of initiating antimalarial chemotherapy.
On the 4th day of chemotherapy, as he went to sleep at 10 P.M, he began to experience recurrent, vivid, terrifying, formed perceptions. "within two minutes of closure of my eyes a "Cyclone" approached me. It came very fast towards my head, made a swift turn over my head and disappeared with a swoosh sound. Two seconds later I saw a well built, huge black unfamiliar person confronting me. He physically squeezed my body. I inturn acted out to releave myself from 'his' clutches. Few seconds later I saw a fair lady, she was stark naked. IL felt as though, she was lying besides me and holding on to me she disappeared within a few seconds I was sweating intensely and breathing heavily. I put on the lights and rang up my family doctor". He narrated as per doctor's advice, he took a Tranquilizer? and slept well. There was no history of headache vomiting, fever, disorientation, memory loss of seizures antedating this experience. There was no history of any substance use, past history or family history of psychiatric illness.
Even though Mr. B perceptual experience was real at that time, on retrospect he could recognise it as unreal. Mental status examination cross sectionaly revealed no psychotic features. His attention, concentration, orientation and memory were intact. There was no automatic disturbances or excited behaviour. Psychometry revealed no features of organic brain syndrome.   
He was advised to continue chloroquine and primaquine, under cover of anti psychotics. Hence he was started on haloperidol 1.5mg BD AND Nitrazepam 5mg. Hs.  Gradually the antipsychotic were tapered . He had no hallucinatory experiences since then.

DISCUSSION
A vast array of drugs are known to cause hallucination, most of them often visual nature. Hallucination can be seen in drug - related non specific confessional status or during withdrawal from various drugs, but they can occur in clear - sensorium also (FISHER,1991). 
The major groupings have been suggested (CUMMINS 1985) (1). Hallocinogens such as LSD, Mescaline, Amphetamine, cocaine, Phencyclidine, Nitrous Oxide. (2). Toxic substance such as antidepressants, antiparkinsonian agents, Hormons (Steroids, thyroid,Antibiotic (Sulfonamides), Bromides,Anticholinergic agents, Digitalis, Propranolol, Heavy metals, Narcotics, Phenacetin. (3) Sedative/hypnotic drugs such as Alcohol, Barbiturates, Benzodiazepines, Chloral Hydrate, Opiates, Cocaine.
Visual Hallucination in primary psychiatric disorders differ from, those in the disorders listed above in several qualitative features. The hallucination associated with functional psychiatric disorders tend to be auditory and complex usually accompanied by  delusions. 
The exact prevalence of psychiatric complications of chloroquine are not yet known. A hospital based study of Chloroquine induced psychiatric syndroms showed 43.3 % affected were children and a predominance of females (BHATIA & MALIK 1994). Cases developed psychosis after receiving a total dose of 1.0 to 2.4gm, and within 2 to 7 days. The period of onset was minimum for organic psychosis followed by schizophrenia like, depression- like and mania - like psychosis. The common behavioural changes noted in patients were agitation, confusion, disorientation, irrelevant and incoherent talk, hallucinations ( visual and auditory), delusions ( control, reference, grandiose and somatic) and suicidal and homicidal ideation. Our case is unique in the sense that hallucinations occurred while on closure of the eyes and the sensorium was clear., added to perception of the experience as unreal in retrospect..
REFERENCES
1.SHADER.N.I (1972):"Psychiatric complications of Medical Drugs: New york: Raven Press
2.REAGAN.E.(1985): " Psychiatric symptoms in volunteers serving overseas" . Lancet 2,37-39
3.GOOD.H.I. & SHADER R.I.(1977):" Behavioural toxicity of chloroquine and it's derivatives".American Journal of Psychiatry. 134,798-801
4.BHATIA.M.S (1991): "Chloroquine induced psychiatric complications" . British Journal of Psychiatry. 159,735
5.FISHER.C.M. (1991):" visual hallucinations on eye closure associated with atropine toxicity ". Canadian Journal of Neurological Sciences. 18,18-27.
6.BHATIA. M.S & MALIK .S.C (1994): " Psychiatric complications of chloroquine" . Indian Journal of Psychiatry 32(2), 85-87.
7.CUMMINS. J.L :Clinical neuropsychiatry, Orlando F.L,Grune & Stration, 1985
BHATIA.M.S & MALIK.S.C (1994): "Psychiatric complications Chloroquine" . Indian Journal of Psychiatry 32(2),95-87.
*PG STUDENTS
** ASST.PROFESSOR
*** ASST. PROFESSOR
**** PROFESSOR & HEAD OF DEPARTMENT
DEPARTMENT OF PSYCHIATRY, MEDICAL COLLEGE , TRIVANDRUM 695011