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.
Background Psychotic symptoms associated with hypothyroidism, also known as "myxedema psychosis," are a treatable cause of psychosis often associated with complete recovery. While most cases receive ...both thyroxine and a short course of antipsychotics, some reports indicate that symptoms can resolve without antipsychotic treatment, though follow-up in these cases has often been short or not reported. This is one of the first case reports demonstrating sustained remission of psychotic symptoms at 6 months in a case of myxedema psychosis treated with minimal antipsychotic medication. Case presentation We describe the case of a 40-year-old Caucasian woman who was brought to hospital with a 7-day history of anxiety and decreased sleep and 1 day of disorganized speech, paranoid delusions, and auditory hallucinations. After being admitted to psychiatry for management, screening blood work revealed elevated thyroid-stimulating hormone. The patient was initiated on treatment with levothyroxine and low doses of antipsychotics. Her symptoms resolved on the third day of her admission with ongoing symptomatic remission at 6 months follow-up. Conclusions The identification of myxedema psychosis is important owing to the implications on treatment and prognosis of the disorder. Our case suggests that sustained symptom resolution may occur with little to no antipsychotic treatment, though these findings are preliminary and additional study is needed before definitive conclusions on the optimal approach can be made. Keywords: Myxedema madness, Myxedema psychosis, Hypothyroidism, Psychotic disorders, Thyroxine, Antipsychotic agents, Thyroid-stimulating hormone
Hypothyroidism has been associated with mood disorders, sometimes with acute psychosis, hence this report. A 45-year-old married female, working as a daily-wage laborer, was brought with marked ...irritability, suspiciousness, wandering about, decreased sleep, appetite, and personal care for the past 1½ years. She had attempted suicide three times in the initial 6 months of illness. She had an asthenic body type; dry, hairless skin; hoarse voice; and nonpitting pedal edema. Deep tendon reflexes were delayed. High thyroid-stimulating hormone levels and positive anti-thyroid peroxidase antibody led to the diagnosis of severe hypothyroidism. Based on her psychiatric evaluation, a diagnosis of organic schizophrenia-like disorder (myxedema madness) was made. She was managed with olanzapine and haloperidol along with thyroxine supplement. The patient improved significantly following thyroxine supplementation and modified electroconvulsive therapy sessions. Herewith, we present this unique case of myxedema madness with suicidal attempts for its uniqueness and rarity.
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.
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.
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.
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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