A 67-year-old male Saudi patient was referred to our psychosomatic service. The patient was a retired elementary school teacher from Al-Qassim province, Saudi Arabia, and due to difficulty in communicating with the patient, the medical history was obtained from his sons. The patient had a history of hypertension and symptoms of benign prostatic hypertrophy for many years. Three years prior to presentation, he began to have repetitive behaviors; in particular, checking and rechecking his underwear for possible urine remnants, which intruded on his prayer duties in the mosque and was noticed by his sons. His thoughts became more intrusive as he planned to do Umrah (minor pilgrimage) to the holy city of Makkah, when he started to repeatedly ask questions about religious rulings. He went on to express excessive worry about his responsibilities towards his family's ownership and inheritance. His condition progressed into continuous fear and worry throughout the day that began to disturb his sleep, first with sleep interruption and later with more persistent insomnia. The sons described a special pattern to their father's anxiety; extreme worry associated with description of palpitations, or occasionally numbness, at the beginning of the day (at dawn prayer) followed by failure to resume sleep in an effort to reduce his anxiety. The symptoms progressed throughout the day, culminating in a more severe and persistent form associated with continuous fatigue by sunset. After sunset, the patient experienced considerable relief and could resume enjoying the company of his family and friends.
No specific triggers to the patient's anxiety were described; there was no history of specific fears, flashbacks, or avoidant behaviors, and his sons did not observe irritability. The patient was witnessed crying only three times over this period, but did not experience persistent low mood, and had normal appetite except over the last few weeks of his illness. He did not report any suicidal ideation.
There was no family or personal history of other psychiatric disorders. Premorbid, he was described as an introverted religious person who, while active at family gatherings, only reluctantly socialized with strangers.
In the 3 years prior to presentation, the patient also frequently described "chest heat", but, given the context of symptoms, his sons ascribed this to a psychological rather than organic cause. The patient therefore presented to several local psychiatrists during this period who diagnosed GAD. He was initially prescribed paroxetine 10 mg once daily (od) for 2 months, to which he showed no response. He was then switched to escitalopram, initially at a dose of 5 mg od, and then 10 mg od for about a year, which was accompanied by a small improvement, but he complained of a feeling of lethargy. Escitalopram was later replaced with mirtazapine 15 mg and fluvoxamine 50 mg (later increased to 100 mg) for another 6 months, but with no response. The last course was replaced finally with sertraline 50 mg od (later increased to 75 mg), again with no response. No significant side effects were reported during the use of these medications.
The cyclical nature of the patient's anxiety symptoms and, finally, deterioration of his condition encouraged his sons to seek medical advice at a tertiary center. The patient was referred to our hospital and electively admitted. He presented with a 6-week history of continuous fever, a reduced level of consciousness, mild dry cough, moderate loss of appetite and weight, and left-sided weakness. There was no history of chest pain, hemoptysis, nausea, vomiting, headache, dizziness, or syncope. A chest X-ray showed bilateral nodular lesions in the lungs (Figure 1). A computed tomography (CT) scan was performed to rule out stroke and showed mild brain atrophy with ischemic changes in the small vessels. A magnetic resonance imaging scan revealed small left corpus callosum lacunar infarcts as well as extensive small vessel disease, in addition to widespread multiple enhancing lesions in the cerebral white matter, brain stem, and cerebellum (Figure 2A and B). Sputum and blood cultures were positive for M. tuberculosis. The patient was therefore diagnosed with miliary TB involving the brain. An abdominal and pelvic CT scan showed normal adrenal glands, and a cortisone challenge test and adrenocorticotropic hormone challenge test were normal. Electroencephalography showed diffuse background slow-waves.
During the admission, the patient was disorientated in time and place, and experienced episodes of visual hallucination. The patient's final diagnoses were delirium of hypoactive type (current) and anxiety disorder secondary to miliary TB (past). Different doses of risperidone were prescribed with the patient showing mild improvement at a dose of 1.5 mg. Eventually, the patient responded to antituberculosis treatment without any anxiety or depressive manifestations, but with residual paraplegia and dementia.