The patient 21-year-old male presented 1 year back with fever for over 1 month, after detailed investigations including cerebrospinal fluid (CSF) examinations, he was diagnosed as a case of tubercular meningitis and was under remission and surveillance on anti-tuberculosis treatment-4 (ATT-4) (HRZE: Isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months, followed by ATT-2 (HR) regularly for 9 months, when he reported a swelling over his left supraclavicular region, on fine needle aspiration cytology (FNAC) this enlarged left supraclavicular lymph node showed tubercular abscess. Development of abscess despite being on regular ATT for 11 months was considered as multidrug resistance tuberculosis (MDR-TB); and hence, started on second line ATT, that is, cycloserine 500, ethionamide 500, ofloxacin 800 in two divided doses and streptomycin 750 mg per day along with continuation of ATT-2. After taking these medications for 7-8 days, he developed symptoms of excessive talkativeness, decreased need for sleep, irritable-aggressive behavior, overactivity, overfamilarity, and inflated self-esteem; and referred for psychiatric consultation.
There was no past or family history of any significant psychiatric or medical illness; his general physical examinations were confirmatory of left supraclavicular lymph node enlargement. On mental status examinations, he had increased psychomotor activity, pressured speech, elated affect, and delusion of grandiosity. Young Mania Rating Scale (YMRS) score was 38, and Brief Psychosis Rating Score (BPRS) score was 51. Cycloserine was considered as most possible offending agent and discontinued, whereas other drugs were continued under close observation as inpatient facility.
He received tab. divalproex 500 mg and olanzapine 5 mg per day initially, then his divalproex was increased to 750 mg/day. After 3 days, his YMRS score was 15 and BPRS was 33 and on 10th day there was no sign of manic symptoms. A score of 5 on Naranjo algorithm (Naranjo et al., 1981) suggests probability of cycloserine causing mania. We gradually tapered off olanzapine first then divalproex within a month, and there is no further affective symptoms reported or found on follow-ups. We have taken written informed consent for publication of this case report.