Psychiatric Manifestation in Drug-Resistant Tuberculosis Patients

Dear Editor, Patients with drug-resistant tuberculosis (DR-TB) face challenges in their treatment due to psychiatric concerns. Numerous medications have been linked to this, including fluoroquinolones, cycloserine, isoniazid, ethambutol, and ethionamide. According to the literature, 84.3% of DR-TB received treatment with psychotropic medications. Depressive disorder, mixed anxiety and depression, neurocognitive disorders and anxiety, and medication-induced psychosis were diagnosed in 48%, 23.5%, 4.9%, and 2%, respectively.[1] Cycloserine-induced psychosis is the most life-threatening complication and fairly more common than ethambutol and fluoroquinolones.[2,3] We present a case of cycloserine-induced acute psychosis which remitted after the removal of the offending agent. A 22-year-old unmarried female from a lower socioeconomic class from an urban background with no family history of psychiatric illness and a well-adjusted premorbid personality, known case of multidrug resistant- tuberculosis (MDR-TB) since a month, was referred from pulmonary medicine to psychiatry with chief complaints of irritability, aggressive behavior, overtalkativeness, laughing to self, inappropriate behavior in ward, suspiciousness, and suicidal ideation with disturbed sleep since two days. Mental status examination revealed an irritable affect, irrelevant talks in speech with suicidal ideas, and ideas of reference with a lack of insight and impaired judgment. She was started on olanzapine 5 mg on which she showed some improvement. She was also started on escitalopram 10 mg to which her suicidal ideas subsided. It was advised to pulmonary medicine to investigate the offending drug and accordingly readjust the drug regimen. She showed significant improvement on stopping cycloserine. At present, the patient is stable, shows complete remission, and is on regular follow-ups in the outpatient department of psychiatry along with pulmonary medicine. In this case, cycloserine seemed to be the offending agent which is in agreement to the existing literature which suggests that 9.7–50% of patients receiving cycloserine reported neuropsychiatric adverse effects like anxiety, depression, psychotic features, suicidality, and behavioral changes.[4] The first three months of treatment are when these adverse effects are most likely to manifest themselves. For less severe complications, decreasing the dose of cycloserine is sufficient. However, in some cases, complete cessation is required. Throughout the course of MDR-TB treatment, antipsychotics can be used to manage neuropsychiatric side effects.[5] Patients with TB frequently experience psychological problems like loneliness, stigma, a lack of social support, denial, a sense of hopelessness, helplessness, anxiety, tension, stress, being mistreated by family and society, and depression, which makes them more susceptible toward the origin of psychiatric illnesses. The absence of a reference standard to assess drug-induced psychiatric episodes presents a significant barrier in this area. However, the majority of the present understanding of mental responses to cycloserine comes from case reports, necessitating additional controlled investigations. Drug-resistant tuberculosis patients frequently experience psychiatric manifestations, but they are manageable and rarely necessitate stopping treatment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.