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HYPOTHYROIDISM PRESENTING AS PSYCHOSIS
Myxedema Madness Revisited
Mónica Caldeira, Filipe Perneta, António Caldeira Ferreira, Cláudia Fraga, Luz Reis Brazão
Internal Medicine Department, Hospital Central do Funchal, Madeira Island, Portugal
INTRODUCTION
Hypothyroidism (HYPO) is a common medical condition in the general population. The clinical presentations of thyroid hormone deficiency are diverse, complicated, and often
overlooked. HYPO is a potential aetiology for multiple somatic complaints and a variety of psychological disturbances. The physical complaints are primarily related to metabolic
slowing secondary to lack of thyroid hormone. A variety of central/peripheral nervous system and psychiatric manifestations are common. They include cognitive dysfunction,
affective disorders, and psychosis. The realization that HYPO might be the potential aetiology of an assortment of symptoms is critical in the identification and treatment of the
hypothyroid patient. In many cases, the neuropsychological manifestations occur in conjunction with the systemic features of the disease and may be noted only incidentally.
However, signs and symptoms of neurologic dysfunction may be the presenting feature in some patients and can contribute significant disability. Once HYPO is identified,
symptoms usually respond to appropriate thyroid hormone supplementation.
Aims: Review of recent data about neurological/psychiatric manifestations of HYPO. Methods: Consult of medical file of the patient.
CLINICAL CASE
Caucasian ♂, 79 years old
Past medical history: High Blood Pressure (treated with a Calcium Antagonist and a Thiazide)
Emergency Department: psychosis, confusion, disorientation 7 day evolution
Examination: BP=165/84mmHg; HR=84bpm; Timpanic Temperature=36.3ºC; Extremities: ankles
and pretibial region edema; Neurological Examination: GCS=13, disorientation, echolalia, visual
hallucinations
Laboratory tests: normocytic normochromic anemia (Hb=8,9g/dL; MCV=87fL; MCHC=30g/dL);
urea=52mg/dL, creatinine=1.3mg/L; creatine kinase=1970U/L
Brain Computed Tomography and Magnetic Resonance: normal
Lumbar Puncture: normal
The patient was admitted to the Internal Medicine Department to be studied. The ulterior
laboratory tests performed showed: TSH=18.13UI/L with normal unbound T4. The diagnosis of
Myxedema Madness was done. The response to thyroxine (0,1mg/day) replacement was
excellent, with complete resolution neuropsychiatric disorder and normalization of the TSH
levels.
DISCUSSION & CONCLUSIONS
Patients with thyroid dysfunction frequently experience a wide variety of
neuropsychiatric presentations and their subtle manifestations make HYPO a
diagnosis that is easy to miss. As a result, it is imperative to remember that
many patients presenting with psychiatric disorders may have alterations in
endocrine function. Since psychiatric complaints may be one of the earliest
manifestations of HYPO, they are often misdiagnosed as functional psychiatric
disorders, rather than a psychiatric disorder due to a general medical condition.
This confusion leads to a delayed treatment and a high likelihood of increase
morbidity. Nowadays myxedematous madness is less common because doctors
are more aware of the condition and patients are diagnosed and treated earlier in
the course of their thyroid deficiency.
References
Heinrich TW, Grahm G; Hypothyroidism Presenting as a Psychosis: Myxedema Madness Revisited; Prim Care Companion J Clin Psychiatry; 2003 Dec; 5 (6): 260-266
Davis JA; Myxoedema madness; J R Soc Med, 1998 May; 91 (5): 291
Shaw E, Halper J, Yi PE, Asch S; Diagnosis of “myxedema madness”; Am J Psychiatry; 1985 May; 142 (5): 655