Nancy E. Broskie, MD

Private Practice, Salem, OR; Affiliate Assistant Professor, Oregon Health and Science University, Portland, OR

First published in Psychiatry Weekly, August 2013, 8(17).

Introduction

Coenzyme Q10 (CoQ10) is an antioxidant supplement that could reduce Parkinsonism,1 aid migraine prophylaxis,2 and increase energy.3 CoQ10 is produced in the body simultaneously with cholesterol, which is inversely related to severity of both depression4 and Parkinsonism.5 Basal ganglia calcification can be caused by hypoparathyroidism with hypocalcemia.6 Two patients with low baseline parathyroid hormone (PTH) and extrapyramidal symptoms tried CoQ10 for energy and migraine prophylaxis, during which time they had transient psychosis that remitted when CoQ10 was discontinued.

 

Patient 1

“Ms. D” is a 39-year-old single, mildly obese female with PTSD, bipolar I disorder, possible mitochondrial neurogastrointestinal encephalomyopathy, gastroparesis necessitating a gastric pacemaker, negative MS workup but internuclear ophthalmoplegia/opthalmoparesis, no constipation, Pisa syndrome, choking on fluid, masked facies, migraines, past significant facial tardive dyskinesia, polycystic ovaries, PTH 9 pg/ml, ferritin 15 ng/ml, low thyroid (corrected), vitamin D 21 ng/ml corrected to 46 ng/ml, normal CMP, phosphorus mid/normal, and IGF-I 230 ng/ml. For fatigue she tried CoQ10 10 mg, but discontinued after 1 week after she began seeing spiders; she experienced no reduction in fatigue. One month later, CoQ10 was restarted at 100 mg, and the visual hallucinations returned within 48 hours. Hallucinations abated within several days of stopping CoQ10. She was also receiving ziprasidone 80 mg/day, pravastatin 40 mg/day, lamotrigine 150 mg b.i.d., gabapentin 900 mg/day, and duloxetine 60 mg/day. Spider hallucinations returned 6 months later, along with non-remitting voices, neither of which fully disappeared even with clozapine.

 

Patient 2

“Mrs. F” is 43 years-old, married, and obese with PTSD, bipolar I, intractable migraines with vomiting, s/p adrenalectomy for high metanephrines 12 months before the CoQ10, s/p splenectomy, mild hypercholesterolemia, chronic neck pain from an injury, chronic fatigue, fibromyalgia, severe restless legs and nocturnal leg cramps, increased neck and trunk muscle tone, en bloc turning, masked facies, low- to mid-normal calcium, and phosphorus, initial vitamin D of 4 ng/ml that was corrected, PTH of 5, and IGF-I 80 ng/ml. She had a history of narcotic overuse. She took CoQ10 100 mg/day for 6 weeks and developed paranoia and auditory hallucinations. She was also receiving topiramate 200 mg b.i.d., lorezapam 2 mg t.i.d., aripiprazole 10 mg/day, olanzapine 25 mg/day, gabapentin 900 mg/day. She had recently shown normal results of the following tests: head CT, CBC with diff, thyroid panel, CMP, and cholesterol (LDL 78 mg/dl, triglycerides 170). Since stopping CoQ10 she has had no recurrence of psychosis to date, more than 6 years later.

 

Conclusion

CoQ10 has been shown to cause transient hypercalcemia in a small study of hypoparathyroid patients.7 We did not check a calcium, but simply stopped what we believed at the time to be the offending agent. More than 10 other patients at our facility with normal to high PTH levels have self-medicated with CoQ10 without psychosis. Low PTH levels, owing perhaps to antipsychotics, may have allowed these two patients to be more susceptible to psychosis with CoQ10.

 

Disclosure: Dr. Broskie reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest. This case report was developed in accordance with HIPAA and with the consent of the internal review board of Oregon Health & Science University.

References:

1. Shults CW, Oakes D, Kieburtz K, et al. Effects of coenzyme Q10 in early Parkinson disease: evidence of slowing of the functional decline. Arch Neurol. 2002;59:1541-1550.

2. Sándor PS, Di Clemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology. 2005;64:713-715.

3. Crane FL. Biochemical functions of coenzyme Q10. J Am Coll Nutr. 2001;20:591-598.

4. Lehto SM, Hintikka J, Niskanen L, et al. Low HDL cholesterol associates with major depression in a sample with a 7-year history of depressive symptoms. Prog Neuropsychopharmacol Biol Psychiatry. 2008;32:1557-1561.

5. Gao J, Huang X, Park Y, et al. Apolipoprotein E genotypes and the risk of Parkinson disease. Neurobiol Aging. 2011;32:2106.e1-6.

6. Zisimopoulou V, Siatouni A, Tsoukalos G, Tavernarakis A, Gatzonis S. Extensive bilateral intracranial calcifications: a case of iatrogenic hypoparathyroidism. Case Rep Med. 2013;2013:932184.

7. Papadimitriou A, Hadjigeorgiou GM, Divari R, et al. The influence of coenzyme Q10 on total serum calcium concentration in two patients with Kearns-Sayre syndrome and hypoparathyroidism. Neuromuscul Disord. 1996;6:49-53.