EPA-0158 – Generalized anxiety as main symptom of chronic appendicitis - a case report

A growing body of literature suggests that proinflammatory cytokines may be causally associated with psychiatric symptoms. Illnesses characterized by chronic inflammatory responses are associated with depression. Studies of cytokines and anxiety symptoms are rare, but provide robust evidence that subjects with anxiety have significantly increased levels of interleukin-6 and tumor necrosis factor alpha. The authors report a clinical case of a 76-year-old man who was referred by the outpatient surgery clinic to liaison psychiatry consultation. He presented a history of chronic anxiety, mild suspicion, insomnia, anorexia and constipation. He was medicated sequentially with benzodiazepines, antidepressants and lastly antipsychotics - he had no response to any of these medications. Analytically he had mild leukocytosis and cranial computed tomography scan was normal. After two months of follow-up there was a clinical deterioration, with significant weight loss and hypotension. A month later he became seriously ill with prostration, abdominal pain and marked hypotension. He was admitted in an intensive care unit and died of peritonitis following rupture of a chronic appendicitis. There is evidence that antidepressants reduce the release of proinflammatory cytokines and increase the release of endogenous cytokine antagonists. The literature shows less consistent findings on the potential anti-inflammatory effects of antipsychotics. Risperidone has been shown to reduce proinflammatory cytokines. This case report suggests that treatment with antidepressants and antipsychotics masked physical symptoms, reduced pain and acute inflammation, contributing to the chronicity of the appendicitis process and delaying the diagnosis, with a fatal outcome.