Nephrol Dial Transplant Vol. 20 No. 2 © ERA–EDTA 2005; all rights reserved
Letter
Body dysmorphic disorder due to hirsutism in a patient treated with cyclosporin
Sir,
Currently administered immunosuppression schemes usually include cyclosporin. Cyclosporin has brought about a revolution in patient prognosis and in renal graft survival, but, unfortunately, it has many side effects [1,2]. While physicians are attentive to the more serious and life threatening of these side effects, there are others which, although not life threatening, can compromise the patient's quality of life. To the latter group belongs hirsutism. The incidence of cyclosporin-induced hirsutism in renal graft recipients is 
5% [1,2].
We describe the case of a 20-year-old male patient with end-stage renal disease due to Alport's syndrome. After 5 months on haemodialysis, the patient received a renal transplant from his father. On discharge from the hospital, the patient was taking Medrol 56 mg/day, mycophenolate mofetil 1.5 g/day and cyclosporin A 400 mg/day. Over a 3 month period, he developed heavy hirsutism of the face and body, which affected both his mood and his social behaviour. He withdrew from his daily activities, became socially isolated and declared that he would stay at home and stop his education. At that time, his serum creatinine was 1.1 mg/dl. The patient was referred to a psychiatrist and the final diagnosis was body dysmorphic disorder [3]. It must be noted that in our department, a psychiatric examination is obligatory for any transplant candidate. In this case, the examination was done a few months before transplantation and showed no psychiatric disorder. Because of this, and despite the good graft function, cyclosporin was switched to tacrolimus (10 mg/day), an efficient immunosupressive drug that dose not cause hirsutism [1,2,4]. The hirsutism disappeared gradually, and both the mood and behaviour of the patient were restored. One year later, the patient's serum creatinine is 1.2 mg/dl and the dose of tacrolimus is 5 mg/day.
Although hirsutism occasionally leads to patient non-compliance, our patient was compliant with medications, but he also fulfilled the criteria oulined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) of the American Psychiatric Association for body dysmorphic disorder [3]. These criteria are: (i) preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive; (ii) the preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning; and (iii) the preoccupation is not better accounted for by another mental disorder.
Body dysmorphic disorder is a serious situation that needs psychiatric evaluation as it is often accompanied by major depression; suicide attempts are rather common [5].
In conclusion, physicians should take care, not only of directly life-threatening side effects of an immunosuppressive regimen, but also of other side effects that can compromise the patient's quality of life. In this case, the switch from cyclosporin to tacrolimus was enough to restore the patient's physical and mental status.
Conflict of interest statement. None declared.
Organ Transplant Unit Hippokratio General Hospital Thessaloniki Greece Email: elefthe{at}otenet.gr
References
- Raimund M. Efficacy and safety of tacrolimus compared with cyclosporin microemulsion in renal transplantation: a randomized multicentre study. Lancet 2002; 359: 741–746[CrossRef][ISI][Medline]
- Montagnino G., Krämer BK. Efficacy and safety of tacrolimus compared with cyclosporin microemulsion in kidney transplantation: twelve-month follow-up. Transplant Proc 2002; 34: 1635–1637[Medline]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association, Washington, DC: 1994
- Thorp M, DeMattos A, Bennett W, Barry J, Norman D. The effect of conversion from cyclosporine to tacrolimus on gingival hyperplasia, hirsutism and cholesterol. Transplantation 2000; 69: 1218–1220[CrossRef][Medline]
- Phillips KA. Body dysmorphic disorder: diagnosis and treatment of imagined ugliness. J Clin Psychiatry 1996; 57 [Suppl 8]: 61–64
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