Patient had a Packed Cell Volume of 26% Total white cell count was 3.5 × 10/L 9, (differentials - Neutrophils 30%, lymphocytes 66%, monocytes 4%, basophils 0%, eosinophils 0%). Thyroid ultrasound scan done showed a multinodular goitre. Thyroid function tests done before patient was referred to our centre showed: T - 330.9 ng/dL (Normal = 69-202 ng/dl), T4 -261.6 nmol/L (Normal -58.7-103 nmol/l) and TSH - 0.12 microIU/L (Normal = 0.32-5.2 microIU/L).Ī repeat thyroid function carried out after weeks on antithyroid drugs revealed T3 - 2.1 ng/ml (0.8-2.0), T4 - 163 ng/ml (45-115), TSH - 0.1 microIU/ml (0.54-3.7) and anti thyroid antibody value - 69.5 IU/mL (3.5-7.6). Chest and abdominal examination did not reveal any abnormality. The apex beat was not displaced and the heart sounds were normal. She had a pulse of 120 beats/minute blood pressure of 120/70 mmHg. The patient was very uncooperative and had no insight. There were persecutory delusions towards relatives, especially her mother. Her speech was irrational, with flight of ideas. She was irritable and threatening as well as talkative and abusive. The initial mental state examination showed that she was poorly groomed and restless. Her speech was irrelevant, was deluded and had no insight.
The central nervous system examination revealed a conscious agitated woman. The anterior neck swelling, measured about 6 by 8 cm, moved with swallowing but not with protrusion of the tongue, firm to hard in consistency, with a smooth surface, no retrosternal extension present, no palpable regional lymph nodes present and no bruits were heard.
She had tremors on the outstretched hand as well as increased pigmentation of the skin. She has no family history of psychiatric illness.Ĭlinical examination revealed a chronically ill - looking woman with staring gaze, lid lag, lid retraction and was mildly pale. Prior to her return to Nigeria, she had worked as a social worker in the UK. She had no past or family history of psychotic behavior. Patient returned to Nigeria from the UK where she lived for 11 years about 8 months prior to presentation with the aim of setting up a small scale business. No history of change in the quality of the voice, difficulty in breathing or swallowing and neck pain. No associated passage of frequent loose stools. There has been significant weight loss despite increased appetite. She also noticed increased pigmentation of her skin. Her friends had drawn her attention to protrusion of her eyes but can not recall when exactly. There was associated history of palpitations, excessive sweating, and tremulousness. The neck swelling has been increasing in size. She had noticed anterior neck swelling 30 months earlier in the UK and was placed on iodized salt by her general practitioner. On discovery, that patient also had features of hyperthyroidism she was referred to us for medical treatment. Rather than improving, her condition worsened which necessitated a search for an organic cause of her illness. She was managed as paranoid schizophrenia and was placed on antipsychotic medications. No history of extravagant spending but at least on one occasion during this episode she was observed to be giving out some of her belongings without obvious reasons. No history of weepy spells, or feelings of worthlessness, hopelessness, loss of interest in previously enjoyable things, guilt feelings or suicidal ideation. There was no history of fever or head injury prior to onset of illness.
She resisted initial attempts to bring her to hospital. She accused her neighbours of wanting to harm her and then bought a cutlass, threatening to attack anyone who came near her. She moved out of the house to another apartment in the compound where she stayed alone and was often observed to be praying excessively. She was also observed to be sleeping poorly, talking and laughing to self, and neglecting her personal hygiene. From then on, she was observed to be increasingly suspicious of her mother, and would not interact with other members of the family.
She accused her mother of stealing her property and that she had come to take them back. In November 2006, she had arrived in Nigeria unexpectedly, calling her mother from the airport and abusing her, calling her a witch. She was living in the UK prior to the onset of illness but often visited her relations in Nigeria from time to time. A 43-year-old female Nigerian was referred to us from a nearby psychiatric hospital where she was hospitalized for four weeks on account of an eight months history of violent behavior, accusing her mother of being a witch, and 2 months history of keeping to self, poor sleep, talking and laughing to self, threatening to harm neighbours, poor personal hygiene and weight loss.
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