The patient was a 43-year-old man with severe restlessness, who was referred to the psychiatric ward of 22 Bahman Hospital in Qazvin Province, Iran. According to the patient’s description, the onset of symptoms was about 2 months before his visit to our hospital. At first, the patient had experienced restlessness and sleep disturbances, especially early morning awakening. According to his description, his restlessness increased as soon as he woke up, and he started asking others for help. The patient’s companions believed that he had become talkative over the past 2 months and that in his speech, he was asking for help due to restlessness. The patient was restless at the time of his visit and was walking constantly. Examination of his mental status revealed that he had an anxious mood, but there was no specific pathological finding in his thought patterns.
One week before admission, the patient was referred to a psychiatrist and treated with medications, including fluoxetine (20 mg), amitriptyline (25 mg every night), risperidone (1 mg), propranolol (40 mg; half a tablet in the morning, and half a tablet at night), and chlordiazepoxide (10 mg; one tablet in the morning and one at night). However, no improvement was seen in his symptoms. One month before his admission, a history of impotence was found in the patient’s clinical history, which did not improve with sildenafil. There was no major finding in the patient’s psychiatric history or history of medication use, especially in terms of hypnotic, antimuscarinic, and anticonvulsant medications. The patient was also examined for substance use, such as opioids, methamphetamine, and cannabis, but no substance use disorder was observed. Besides, there was no considerable finding in the patient’s family history.
Mental status examination
In the mental status examination, the patient’s attitude was semi-cooperative. In terms of psychomotor activity, restlessness, high speech volume, spontaneous speech, anxious mood, and mood congruence effect were reported. Except for impaired concentration, no specific pathological finding was reported in the cognitive assessments or the Mini-Mental State Examination (MMSE).
Neurological examinations
The cranial nerve examination was normal. In the motor examination, the muscle volume and tone also were normal. The muscle strength was found to be 5/5 (the muscle worked normally and could maintain its position). Also, examinations of the sensory system, abdominal, plantar, and deep tendon reflexes were normal. No significant findings were found in the ophthalmoscopic examination. The patient’s gait and cerebellar examinations were also normal.
Moreover, the patient’s vital signs were completely normal. At the onset of hospitalization, necessary tests were performed to rule out medical disorders associated with restlessness, such as fever, infection, and electrolyte disorders (i.e., a pathological increase in serum calcium). To start medications, fasting blood sugar (FBS) tests, lipid profile, liver function test, thyroid function test, electrolytes (i.e., sodium, potassium, calcium, and phosphorus), creatinine, blood urea nitrogen (BUN), complete blood count (CBC), urine toxicology, and electrocardiogram (ECG) were requested, all of which were reported to be normal.
Next, the patient was asked to undergo a brain CT scan, which was not performed on the first day of hospitalization due to his severe restlessness and was postponed until it was managed. lorazepam was prescribed to control the patient’s restlessness, which was changed to clonazepam (1 mg in the morning, 1 mg in the afternoon, and 2 mg at night) due to the ineffectiveness of lorazepam. Medications, including Rahakin (sodium valproate, 500 mg twice daily), olanzapine (5 mg twice daily), and propranolol (10 mg three times daily), were prescribed, with an initial diagnosis of bipolar disorder not otherwise specified (NOS). His restlessness was partially controlled 2 days after receiving the drug combination, but he developed ataxia. In the meantime, a brain CT scan was performed.
After performing CT scan and observing the mass, the patient underwent magnetic resonance imaging (MRI), as suggested by the neurosurgeon; a large mass was detected in the right temporal and occipital lobes. Figure 1 a, b, and c show the axial and coronal views of the T2-weighted MRI image of the brain without contrast. The tumor dimensions were 100 × 60 × 50 mm, as can be seen in the right temporal and occipital lobes. This tumor had compressed the third ventricle, midbrain, and right lateral ventricle, shifting the midline elements and enlarging the left lateral ventricle (Fig. 1). Consequently, the patient was transferred to the neurosurgery service.