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Lipkes C, Haider S, Rashid A, Angarita GA, Riley S. First Episode Psychosis and Pituitary Hyperplasia in a Patient With Untreated Hashimoto's Thyroiditis: A Case Report. Front Psychiatry 2022; 13:863898. [PMID: 35401262 PMCID: PMC8987109 DOI: 10.3389/fpsyt.2022.863898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
This case report describes a woman with no psychiatric history and previously diagnosed Hashimoto's thyroiditis who presented to the psychiatric emergency department with a first episode of psychosis. The initial workup for organic causes of psychosis revealed an astronomically high thyroid stimulating hormone (TSH) (> 1,000 μIU/mL) out of proportion to the patient's minimal physical symptoms of hypothyroidism. Additionally the patient's head imaging showed an enlarged pituitary, a rare, but reversible, presentation of chronically untreated primary hypothyroidism. The patient was transferred to a medical unit to receive IV thyroid hormone replacement as well as an adjunctive antipsychotic to assist with remission of her distressing auditory hallucinations and persecutory delusions. This case highlights the importance of a thorough medical workup for causes of new onset psychosis and the need for further consensus in the literature regarding choice of antipsychotic and duration of treatment for psychosis secondary to hypothyroidism.
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Affiliation(s)
- Celeste Lipkes
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States.,Department of Mental Health, Charles George Veterans Affairs Medical Center, Asheville, NC, United States
| | - Shanzay Haider
- Department of Endocrinology, Yale University School of Medicine, New Haven, CT, United States
| | - Ali Rashid
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Gustavo A Angarita
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States.,Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven CT, United States
| | - Sarah Riley
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
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Pattaravimonporn N, Chaikijurajai T, Chamroonrat W, Sriphrapradang C. Myxedema Psychosis after Levothyroxine Withdrawal in Radioactive Iodine Treatment of Differentiated Thyroid Cancer: A Case Report. Case Rep Oncol 2021; 14:1596-1600. [PMID: 34950002 PMCID: PMC8647114 DOI: 10.1159/000520128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022] Open
Abstract
Neuropsychiatric symptoms, especially acute psychosis (often referred to as myxedema madness or psychosis), are rare but possible clinical presentations of patients with hypothyroidism. A 42-year-old woman with papillary thyroid carcinoma and recent total thyroidectomy had developed flat affect, paranoid delusion, and visual and auditory hallucination during inpatient admission for elective radioactive iodine treatment. On admission, her history and physical exam did not reveal symptoms and signs of significant hypothyroidism. Other medical causes of acute psychosis were excluded, and the patient was immediately treated with thyroid hormone replacement therapy. Subsequently, her thyroid function normalized, and her psychotic symptoms gradually improved. Although there is a lack of classic signs and symptoms of hypothyroidism, myxedema madness should be recognized as one of the potentially treatable causes of acute psychosis.
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Affiliation(s)
- Nutnicha Pattaravimonporn
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanat Chaikijurajai
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Internal Medicine Residency Program, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Wichana Chamroonrat
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chutintorn Sriphrapradang
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Krüger J, Kraschewski A, Jockers-Scherübl MC. Myxedema Madness - Systematic literature review of published case reports. Gen Hosp Psychiatry 2021; 72:102-116. [PMID: 34419786 DOI: 10.1016/j.genhosppsych.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/07/2021] [Accepted: 08/11/2021] [Indexed: 12/23/2022]
Abstract
Myxedema Madness is a rare but easily treatable cause of psychosis. Since Myxedema Madness was first described the question of a specific psychopathological symptom complex caused by severe hypothyroidism was raised in the literature. The present review of 52 published cases indicates that there are no specific somatic and psychopathological findings to diagnose a myxedema psychosis. It is diagnosed through the measurement of thyroid stimulating hormone and treated by application of L-thyroxine. Due to its excellent prognosis, myxedema madness should always be considered a differential diagnosis in new onset psychosis.
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Affiliation(s)
- Jana Krüger
- Oberhavel Kliniken GmbH, Department of Psychiatry and Psychotherapy, Academic Hospital of the Charité Universitätsmedizin Berlin, Marwitzer Straße 91, 16761 Hennigsdorf, Germany.
| | - Adrian Kraschewski
- Oberhavel Kliniken GmbH, Department of Psychiatry and Psychotherapy, Academic Hospital of the Charité Universitätsmedizin Berlin, Marwitzer Straße 91, 16761 Hennigsdorf, Germany
| | - Maria C Jockers-Scherübl
- Oberhavel Kliniken GmbH, Department of Psychiatry and Psychotherapy, Academic Hospital of the Charité Universitätsmedizin Berlin, Marwitzer Straße 91, 16761 Hennigsdorf, Germany
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Mohamed MFH, Danjuma M, Mohammed M, Mohamed S, Siepmann M, Barlinn K, Suwileh S, Abdalla L, Al-Mohanadi D, Silva Godínez JC, Elzouki AN, Siepmann T. Myxedema Psychosis: Systematic Review and Pooled Analysis. Neuropsychiatr Dis Treat 2021; 17:2713-2728. [PMID: 34447249 PMCID: PMC8382967 DOI: 10.2147/ndt.s318651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The term myxedema psychosis (MP) was introduced to describe the occurrence of psychotic symptoms in patients with untreated hypothyroidism, but the optimal assessment and treatment of this condition are unclear. We aimed to synthesize data from the literature to characterize the clinical presentation and management of MP. METHODS We performed a systematic review according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines in PubMed (Medline), Embase, Google Scholar, and Cochrane databases, including observational studies, case series, and case reports published from 1/1/1980 to 31/12/2019 in the English language. Descriptive statistics along with univariate and multivariate analysis were used for data synthesis. RESULTS Out of 1583 articles screened, 71 case reports met our inclusion criteria providing data on 75 MP cases. The median age at diagnosis was 42 years [32-56]. About 53% had no prior hypothyroidism diagnosis. Delusions occurred in 91%, with a predominance of persecutory ideas (84%), while hallucinations occurred in 78%. Physical symptoms and signs of hypothyroidism were absent in 37% and 26%, respectively. If symptoms occurred, nonspecific fatigue was seen most frequently (63%). The median thyroid-stimulating hormone value was 93 mIU/L [60-139]. Thyroid peroxidase antibodies were found positive in 75% (23/33) of reported cases. Creatinine kinase was reported abnormal in seven cases. Cranial imaging (CT or MRI) and electroencephalogram were normal in 89%, 75%, and 73% of the cases reported. The majority of patients were treated orally with thyroxine in combination with short-term antipsychotics. More than 90% of them showed complete recovery. Univariate analysis revealed a trend towards a shorter duration of psychosis with IV thyroid hormone therapy (p= 0.0502), but the effect was not consistent in a multivariate analysis. CONCLUSION While we identified a substantial lack of published research on MP, our pooled analysis of case observations suggests that the condition presents a broad spectrum of psychiatric and physical symptoms lending support to the value of screening for thyroid dysfunction in patients with first-ever psychosis. PROSPERO REGISTRATION NUMBER CRD42020160310.
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Affiliation(s)
- Mouhand F H Mohamed
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
| | - Mohammed Danjuma
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
| | | | - Samreen Mohamed
- Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Martin Siepmann
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Salah Suwileh
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Lina Abdalla
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Juan Carlos Silva Godínez
- Department of Surgery, National Medical Center Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
| | - Timo Siepmann
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Severe Hypothyroidism Manifested as Acute Mania With Psychotic Features: A Case Report and Review of the Literature. J Psychiatr Pract 2020; 26:417-422. [PMID: 32936589 DOI: 10.1097/pra.0000000000000497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypothyroidism is associated with a wide array of medical, neurological, and psychiatric symptoms. Severe hypothyroidism may present as myxedema coma, a medical emergency. In addition, patients may present with myxedema psychosis, a psychiatric emergency manifested as hyperactive encephalopathy, hallucinations, delusions, and suicidal ideation. In rare instances, patients may present with symptoms of mania with psychosis. We present the case of a 26-year-old woman with no known psychiatric history who presented with gradual onset of altered mental status, distractibility, decreased need for sleep, pressured speech, and religious and paranoid delusions. Her medical history was significant for a surgically absent thyroid gland and nonadherence to thyroid hormone. The patient was found to have a severely elevated level of thyroid-stimulating hormone, low level of triiodothyronine, and undetectable thyroxine. Thyroid ultrasound demonstrated a surgically absent thyroid gland. The patient's metabolic panel and random serum cortisol level were normal. Rapid plasma reagin was nonreactive, and toxin screening was negative. It was concluded that severe hypothyroidism was the cause of the patient's mania with psychotic features, given her thyroid hormone levels and lack of history of a psychiatric or substance use disorder. Thyroid hormone monitoring and treatment of hypothyroidism is necessary in all patients who have undergone surgical excision of the thyroid gland. All patients presenting with a first episode mania should be screened for thyroid dysfunction. The preferred treatment includes an atypical antipsychotic and thyroid replacement therapy. Rapid resolution of symptoms can occur with combined levothyroxine and liothyronine. Correction of hypothyroidism improves response to antipsychotics.
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Mohamed MF, Mahgoub AB, Sardar S, Elzouki AN. Acute psychosis and concurrent rhabdomyolysis unveiling diagnosis of hypothyroidism. BMJ Case Rep 2019; 12:12/10/e231579. [PMID: 31586959 DOI: 10.1136/bcr-2019-231579] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Neuropsychiatric and muscular symptoms can develop as part of hypothyroidism. However, frank psychosis or rhabdomyolysis due to hypothyroidism are uncommon and have been reported rarely as the first presenting features of hypothyroidism. We report a case of a 44-year-old man who presented with a 2-week history of delusions, hallucinations and mild bilateral leg pain, without apparent signs of myxedema. Investigations revealed raised thyroid stimulation hormone >100 mIU/L and high creatine kinase >21 000 U/L. Diagnosis of hypothyroidism-induced psychosis and rhabdomyolysis was made. He received thyroxine, olanzapine and a short course of steroids. His symptoms improved after 2 weeks of treatment and he remained free of symptoms at 6 months of follow-up. To the best of our knowledge, this is the first case of concomitant psychosis and rhabdomyolysis leading to hypothyroidism diagnosis. This case highlights the importance of hypothyroidism screening when faced with unexplained psychosis or rhabdomyolysis, especially if combined.
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Affiliation(s)
| | - Ali B Mahgoub
- Internal Medicine Residency Program, Hamad Medical Corporation, Doha, Qatar
| | - Sundus Sardar
- Internal Medicine Residency Program, Hamad Medical Corporation, Doha, Qatar
| | - Abdel-Naser Elzouki
- General Internal Medicine, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar
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A Case of Violent Suicide Attempt in a Context of Myxedema Psychosis following Radioiodine Treatment in a Patient with Graves' Disease. Case Rep Psychiatry 2019; 2019:4972760. [PMID: 30729057 PMCID: PMC6343151 DOI: 10.1155/2019/4972760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/30/2018] [Accepted: 12/14/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Hypothyroidism has been associated with mood disorders but some cases of acute psychosis have also been reported. However, less attention has been paid to suicidal behavior in these patients. Case Report We report a case of suicide attempt by self-stabbing in a 43-year-old woman without past psychiatric history, four months after radioiodine therapy for Graves' disease. On clinical examination remarkable signs of myxedema were found and blood investigations showed hypothyroidism with an extremely high thyroid stimulating hormone (TSH) level (152 mUI/L; reference range 0.20-5.10). The patient presented delirium symptoms at the time of self-stabbing, which was associated with persecutory delusions and auditory harm command hallucinations. A rapid physical and psychiatric improvement was observed after the initiation of an oral thyroid replacement therapy without relapse after early discontinuation of the antipsychotic treatment. Discussion The most distinctive feature of our case is that the violent suicide attempt could be attributed to the myxedema psychosis. Suicide may result from several factors, including psychosocial stressors, psychiatric symptoms, and hormonal disturbance. This unique presentation should remind clinicians to systematically consider ordering additional tests in patients with atypical psychiatric presentation, even when serious behavioral disorders (such as violent suicide attempts) are present and may result in premature transfer to psychiatric units.
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Er C, Sule AA. Late onset radioiodine-induced hypothyroidism presenting with psychosis 14 years after treatment: a rare case. Oxf Med Case Reports 2016; 2016:68-70. [PMID: 27099771 PMCID: PMC4836603 DOI: 10.1093/omcr/omw020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 03/04/2016] [Accepted: 03/10/2016] [Indexed: 11/12/2022] Open
Abstract
Radioiodine treatment-induced hypothyroid psychosis is uncommon. Our literature search shows only three cases of hypothyroid psychosis developed within 3 months after the radioiodine treatment. Our case represents the first case of radioiodine-induced hypothyroidism presenting as psychosis much later (14 years) after the radioiodine treatment. A 60-year-old Chinese lady, with long-standing primary hypothyroidism due to the radioiodine treatment performed 14 years ago, presented with a 1-week history of hallucination, delusion and agitation. She was not on thyroid replacement. Thyroid function test done 14 years ago and again upon her admission to our facility was consistent with primary hypothyroidism. General blood tests and brain imaging were unremarkable. Her psychotic features resolved within 1 week with thyroid replacement and 9 days of antipsychotics. No further relapse of psychosis was noted. This emphasizes that radioiodine-induced hypothyroidism can go unnoticed for many years and present much later solely as psychosis.
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Affiliation(s)
- Chaozer Er
- Department of General Medicine , Tan Tock Seng Hospital , Singapore
| | - Ashish Anil Sule
- Department of General Medicine , Tan Tock Seng Hospital , Singapore
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Ueno S, Tsuboi S, Fujimaki M, Eguchi H, Machida Y, Hattori N, Miwa H. Acute psychosis as an initial manifestation of hypothyroidism: a case report. J Med Case Rep 2015; 9:264. [PMID: 26577152 PMCID: PMC4650306 DOI: 10.1186/s13256-015-0744-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/23/2015] [Indexed: 11/28/2022] Open
Abstract
Introduction Hypothyroidism is one of the most important causes of treatable dementia, and psychosis occasionally associated with it is known as myxedema madness. We report a case of a 90-year-old patient who developed myxedema madness acutely without overt clinical symptoms and signs suggestive of hypothyroidism. Case presentation A 90-year-old Japanese man, a general practitioner, was admitted to our emergency room because of acute-onset lethargy, delusions, and hallucinations. He had been actively working until 3 days before the admission. Upon admission, his general physical examination was unremarkable. However, a blood investigation showed the presence of hypothyroidism, and computed tomography revealed pleural effusion and ascites. Electroencephalography revealed diffuse slow waves with a decrease of α-wave activity. A single-photon emission computed tomography scan revealed a decrease of cerebral blood flow in both frontal lobes. The patient was soon treated with thyroid hormone replacement therapy. Following normalization of his thyroid function, both pleural effusion and ascites diminished and his electroencephalographic activity improved simultaneously; however, he did not recover from his psychosis. Conclusions Myxedema madness should be kept in mind in the differential diagnosis of acute psychosis in elderly patients, particularly the oldest patients as in our case, because manifestations of hypothyroidism often may be indistinguishable from the aging process.
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Affiliation(s)
- Shinichi Ueno
- Department of Neurology, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Satoko Tsuboi
- Department of Neurology, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Motoki Fujimaki
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Hiroto Eguchi
- Department of Neurology, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Yutaka Machida
- Department of Neurology, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Hideto Miwa
- Department of Neurology, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan.
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Affiliation(s)
- Vineet Juneja
- Flinders Medical Centre, Margaret Tobin Centre, Bedford Park, Australia
| | - Michael Nance
- Flinders Medical Centre, Margaret Tobin Centre, Bedford Park, Australia
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Feldman AZ, Shrestha RT, Hennessey JV. Neuropsychiatric manifestations of thyroid disease. Endocrinol Metab Clin North Am 2013; 42:453-76. [PMID: 24011880 DOI: 10.1016/j.ecl.2013.05.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The interface between thyroid hormone action and neuropsychiatric function is intricate, and several mechanisms of thyroid hormone uptake into brain tissues, hormone activation, and influences on neurotransmitter generation have been identified. Symptoms of hypothyroidism are nonspecific, whereas those attributed to thyrotoxicosis may be more characteristic. Neuropsychiatric manifestations triggered by thyroid dysfunction likely respond well to reestablishment of the euthyroid state, although some patients have persistent complaints. The addition of LT3 to ongoing LT4 replacement has yet to be definitively shown to be advantageous. Treatment of euthyroid depression with LT3 in addition to antidepressant therapy lacks convincing evidence of superior outcomes.
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Affiliation(s)
- Anna Z Feldman
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Gryzmish 6, Boston, MA 02215, USA
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