Acute psychosis as an initial manifestation of hypothyroidism: a case report

Acute psychosis unveiling diagnosis of hypothyroidism: A case report

Introduction

Hypothyroidism is a common condition in the general population that presents a wide array of medical, neurological and psychiatric symptoms. However, hypothyroidism rarely leads to acute psychosis, termed myxedema psychosis (MP) and is often missed by many physicians.

Case presentation

Here we report a case of a 36-years-old female who presented with a one-week history of abnormal behavior, delusions and hallucinations. Investigations revealed a high thyroid-stimulating-hormone (TSH)of 78.60 mlU/mL and low free thyroxine (FT4) of 0.64 pmol/L. Diagnosed with hypothyroidism, she was treated with oral thyroid hormone replacement (l-thyroxine 75 μg/day) with antipsychotics and her symptoms settled within days. She was discharged off antipsychotics and advised to adhere to thyroxine replacement and to follow up for Thyroid function test (TFT).

Discussion

Myxedema psychosis is an uncommon manifestation of the common endocrine disease hypothyroidism. The atypical nature of presentations occasionally complicates diagnostics. When approaching a 'first-episode psychosis,’ it is essential to perform a complete organic screen consistently.

Conclusion

Acute myxedema madness should be considered in the differential diagnosis of acute psychosis in patients with hypothyroidism.

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Hypothyroidism rarely leads to acute psychosis, termed myxedema psychosis.

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Acute myxedema madness should be considered in the differential diagnosis of acute psychosis in patients with hypothyroidism.

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When approaching a 'first-episode psychosis,’ it is essential to perform a complete organic screen consistently.

Myxedema Madness - Systematic literature review of published case reports

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.

Myxedema Psychosis: Systematic Review and Pooled Analysis

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.

The relation between thyroid dysregulation and impaired cognition/behaviour: An integrative review

Despite decades of research on the relation between thyroid diseases and cognition, the nature of this relationship remains elusive. An increasing prevalence of cognitive impairment and thyroid dysfunction has been consistently observed with ageing. Also, there appears to be an association between thyroid disorders and cognitive decline. Given the increasing global burden of dementia, elucidating the relationship between thyroid disorders as a potentially modifiable risk factor of cognitive impairment was the main goal of this review. We summarise the current literature examining the relationship between thyroid hormonal dysregulation and cognition or behaviour. We present the available imaging and pathological findings related to structural and functional brain changes related to thyroid hormonal dysregulation. We also propose potential mechanisms of interaction between thyroid hormones, autoantibodies and cognition/behaviour. Effects of gender, ethnicity and environmental factors are also briefly discussed. This review highlights the need for long-term prospective studies to capture the course of brain functional changes associated with the incidence and progression of thyroid dysregulations along with the confounding effects of non-modifiable risk factors such as gender and ethnicity. Moreover, double-blind controlled clinical trials are necessary to devise appropriate treatment plans to prevent cognitive consequences of over or undertreatment of thyroid disorders.

Myxedema Psychosis: Neuropsychiatric Manifestations and Rhabdomyolysis Unmasking Hypothyroidism

Background. Hypothyroidism is a prevalent endocrine disorder, often presenting with a spectrum of symptoms reflecting a hypothyroid state. It is also generally linked to causing mood swings, psychomotor slowing, and fatigue; however, in rare instances, it may lead to or induce acute psychosis, a condition referred to as myxedema psychosis (MP). We report a case of myxedema psychosis and present a literature review discussing its presentation, diagnosis, management, and prognosis. Case Presentation. A 36-year-old lady presented with one-week history of persecutory and paranoid delusions, along with visual and auditory hallucinations. She had no prior history of psychiatric illnesses. She underwent total thyroidectomy three years before the current presentation due to papillary thyroid cancer. She was not on regular follow-up, nor any specific therapy. On examination, she was agitated and violent. There were no signs of myxedema, and the physical exam was unremarkable. The initial workup showed a mild elevation in serum creatinine. Additional investigations revealed a high thyroid-stimulating hormone (TSH) of 56.6 mIU/L, low free T4 < 0.5 pmol/L, elevated creatine kinase of 3601 U/L, and urine dipstick positive for blood, suggestive of myoglobinuria. MRI of the head was unremarkable. We diagnosed her as a case of myxedema psychosis and mild rhabdomyolysis. She was started on oral thyroxine 100 mcg/day, fluoxetine 20 mg daily, and as-needed haloperidol. She was closely followed and later transferred to the Psychiatry Hospital for further management. Within one week, her symptoms improved completely, and she was discharged off antipsychotics with additional scheduled follow-ups to monitor TFTs and observe for any recurrence. Discussion and Conclusion. Myxedema psychosis is a rare presentation of hypothyroidism—a common endocrine disorder. Scarce data are describing this entity; hence, there is currently a lack of awareness amongst clinicians regarding proper identification and management. Moreover, the atypical nature of presentations occasionally adds to a diagnostic dilemma. Thus, any patient with new-onset psychosis should be screened for hypothyroidism, and awareness of this entity must be emphasized amongst clinicians and guideline makers.

Ramifications of untreated hypothyroidism: case report of cognitive impairment and acute psychosis in an elderly female

Hypothyroidism is a common condition in the general population. While myxedema is a known complication, we present a case highlighting a late-onset presentation of psychosis with confounding cognitive impairment in a patient who believed she no longer needed thyroid replacement medication because of her advanced age.

Acute psychosis and concurrent rhabdomyolysis unveiling diagnosis of hypothyroidism

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.

Myxedema Psychosis in a Patient With Undiagnosed Hashimoto Thyroiditis

Myxedema psychosis is uncommon in patients with primary hypothyroidism. Most often, this disease state can be found in patients with Hashimoto thyroiditis or after total thyroidectomy. Chronic hypothyroidism can lead to an insidious onset of psychiatric symptoms in patients, such as dementia, delirium, psychosis, hallucinations, and coma. A 31-year-old man with an unremarkable medical history was brought to the psychiatric emergency department for new-onset aggression, paranoid behavior, and hallucinations for 4 days. Initial test results showed a thyroid-stimulating hormone level of 306.0 mIU/L and a free thyroxin level of 0.24 ng/dL. No other clinical or laboratory abnormalities were found. A diagnosis of myxedema psychosis was established, and the patient was treated with tapering doses of intravenous hydrocortisone and 0.1 mg of intravenous levothyroxine daily. On hospital day 3, his mental status began to improve, and he was discharged on day 4. Myxedema psychosis is rarely the initial presenting symptom of hypothyroidism, especially in the absence of other abnormal clinical or laboratory findings.