Delayed dyskinesia and prolonged psychosis in a patient presenting with profound hyponatraemia

Sheehan Syndrome Presenting with Psychotic Manifestations Mimicking Schizophrenia in a Young Female: A Case Report and Review of the Literature

Introduction

Sheehan syndrome presents with features of multiple hormone deficiencies including lactation failure and amenorrhoea as well as with features of central hypothyroidism and adrenocorticotropic hormone deficiency. Psychiatric manifestations are mostly limited to cognitive impairment. Psychotic presentations are rare and limited to case reports. Case Presentation. A 32-year-old female was evaluated for fearfulness and delusions for one year. She had persecutory and bizarre delusions, delusion of thought possession, and elementary auditory hallucinations. These began four months after the birth of her third child. The delivery had been complicated with postpartum haemorrhage. Her symptoms caused the functional decline and progressively worsened, resulting in suicidal ideation. Cognitive assessment revealed mild impairment in attention. Further inquiry revealed lethargy, constipation, cold intolerance, and lactation failure. She was slow, having dry skin, puffy face, and bradycardia with a blood pressure of 80/60 mmHg (supine) and 70/50 mmHg (standing). She had hyponatraemia, elevated creatine phosphokinase, low thyroxine, prolactin, FSH, LH, and IGF-1. She had poor cortisol and growth hormone response to the insulin tolerance test. MRI-pituitary showed empty sella. A diagnosis of Sheehan syndrome was made. Her symptoms improved completely after the initiation of levothyroxine and hydrocortisone.

Conclusions

Sheehan syndrome can present with psychotic symptoms mimicking schizophrenia with variable involvement of cognition. Detailed reporting of these patients would enhance better characterization of the clinical presentation and risk profile of these patients.

Case report: manic episode with psychotic symptoms induced by hyponatremia

In the literature, several cases of an association between hyponatremia and psychotic symptoms have been reported. We present the case of a young Caucasian male presenting with rapid, incoherent speech, religious and megalomanic delusions, and emotional lability. The patient was described by his relatives as being healthy until a few days before admission. He had no significant medical or psychiatric history, except a short drug-induced psychotic episode a few years earlier. Somatic workup showed moderate hyponatremia, but no other abnormalities. Tests for narcotics, in particular, were also negative. Antipsychotic treatment with risperidone was initiated. After normalization of sodium levels using intravenous saline, the patient remitted within a few days and risperidone was discontinued on day 3. He was discharged by day 13 without further pharmacological treatment.

Dysfunction of voltage-gated ion channels, particularly sodium and calcium channels, has been implicated in the pathogenesis of bipolar disorder. We therefore assume a causal relationship between hyponatremia and manic-psychotic symptoms in our patient. Hyponatremia was most likely induced by excessive water intake during a period of fasting in the context of a wellness practice.

Treatment of Severe Hyponatremia

Patients with severe (serum sodium ≤120 mEq/L), symptomatic hyponatremia can develop life-threatening or fatal complications from cerebral edema if treatment is inadequate and permanent neurologic disability from osmotic demyelination if treatment is excessive. Unfortunately, as is true of all electrolyte disturbances, there are no randomized trials to guide the treatment of this challenging disorder. Rather, therapeutic decisions rest on physiologic principles, animal models, observational studies, and single-patient reports. European guidelines and recommendations of an American Expert panel have come to similar conclusions on how much correction of hyponatremia is enough and how much is too much, but there are important differences. We review the evidence supporting these recommendations, identifying areas that rest on relatively solid ground and highlighting areas in greatest need of additional data.