A 56-year-old male, with irritability, aggression, suspiciousness, and sleep disturbances for 1.5 years, presented to psychiatric emergency services after an acute exacerbation. He had a history of irregularly treated type 2 diabetes mellitus and hypothyroidism. Two years earlier, the patient had developed low-grade fever, cough, and weight loss and then diagnosed as pulmonary TB. After three months of anti-TB treatment (ATT), he developed episodes of altered sensorium and generalised tonic-clonic seizures secondary to hyponatremia and normal pressure hydrocephalus, which resolved with conservative treatment (Table 1). One month later, the patient had recurrent dizziness, nausea, and vomiting. Evaluations revealed episodic hyponatremia and reduced serum cortisol. The patient could not afford further investigations. Considering pulmonary TB and physical signs of adrenal insufficiency, tubercular adrenalitis was provisionally diagnosed and empirical steroid treatment was initiated. Poor compliance to steroids resulted in a relapse of adrenal sufficiency along with an acute-onset, continuous course of psychiatric illness characterized by irritability, suspiciousness, and biological and sociooccupational dysfunction leading to the current clinical presentation. His premorbid, past, family, and substance use history were nil contributory. Mental status examination revealed delusions of reference, persecution, and misidentification. The patient was diagnosed with organic delusional (Schizophrenia-like) disorder (F06.2) as per the International Classification of Diseases-10th edition (ICD-10).
Psychosis improved with risperidone (2 to 6 mg/day) (Brief Psychiatric Rating Scale scores: baseline-58 and follow-up-32) over 2-3 months. His adrenal insufficiency was symptomatically managed with an endocrinologist liaison and reinitiation of steroid therapy. Adherence was ensured through telepsychiatry services. Written informed consent was obtained from the patient and caregiver prior to the write-up of this report.