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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