Archives of Medicine and Health Sciences

CASE REPORT
Year
: 2019  |  Volume : 7  |  Issue : 1  |  Page : 90--91

Hypothyroidism presenting as hallucinosis: A clinical masquerade


Sharol Lionel Fernandes, AT Safeekh, Siddharth Shetty, S Chandini 
 Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka, India

Correspondence Address:
Dr. Sharol Lionel Fernandes
Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka
India

Abstract

There is a lot of literature on psychiatric manifestations of thyroid disorders. However, it is uncommon for a thyroid disorder to present purely with psychiatric symptoms. In instances like this, where there is an absence of any symptoms or signs of the medical illness, it can be difficult to arrive at the diagnosis of the correct underlying medical disorder. This case report aims to highlight the diagnostic challenges in consultation-liaison psychiatry in a case of unusual presentation of hypothyroidism with hallucinations.



How to cite this article:
Fernandes SL, Safeekh A T, Shetty S, Chandini S. Hypothyroidism presenting as hallucinosis: A clinical masquerade.Arch Med Health Sci 2019;7:90-91


How to cite this URL:
Fernandes SL, Safeekh A T, Shetty S, Chandini S. Hypothyroidism presenting as hallucinosis: A clinical masquerade. Arch Med Health Sci [serial online] 2019 [cited 2020 Jan 17 ];7:90-91
Available from: http://www.amhsjournal.org/text.asp?2019/7/1/90/260022


Full Text



 Introduction



Disorders of the thyroid gland are probably the most common endocrine disorders worldwide, with India being no exception. Individuals with thyroid dysfunction can present with a variety of symptoms. In addition to the typical physical symptoms, patients with hypothyroidism have also been known to present with psychiatric symptoms. It is known that the thyroid hormones play a critical role in metabolic activity and neuropsychiatric manifestations. Studies have shown that metabolism disturbances of the thyroid can profoundly alter mental function, influencing cognition, and emotion.[1] Rarely, the psychiatric symptoms may be the sole reason for which treatment is sought.

The association between hypothyroidism and psychiatric disorders has been well described. Earlier studies have shown that 5% to 15% of hypothyroid patients have some form of psychosis.[2] The psychiatric manifestations of hypothyroidism can be varied and include cognitive dysfunction, affective disorders, and psychosis.[3] At times, the psychiatric presentation may be so striking that patients are first diagnosed with a primary psychiatric disorder rather than hypothyroidism. The symptoms most commonly related to thyroid deficiency include forgetfulness, fatigue, mental slowness, inattention, and emotional lability. The predominant affective disorder known to be experienced is depression. Perceptual changes may develop with alterations of taste, hearing, and vision. Delusions and hallucinations may also occur as the disease progresses.

No correlation, however, appears to exist between the degree of thyroid dysfunction and psychiatric symptoms that subsequently develop.[4] Thyroid dysfunction, therefore, should not be overlooked as an etiology for behavioral, affective, and cognitive changes.

 Case Report



Mr. A, a 33-year-old male, waiter by occupation was brought to the outpatient department with complaints of hearing of voices, talking to self, and smiling to self for a duration of 3 months. Due to the above complaints, he had been unable to go to work in the last 3 months. There was no history of any head injury, loss of consciousness, or seizures. No history of weight gain, intolerance to cold, constipation, or hair loss was reported. The patient had no history of substance use. The patient had no history of any thought interference, depressive symptoms, or anxiety symptoms.

There was no contributory past or family history.

Physical examination revealed no abnormality. He was afebrile. Pulse was around 78/min and blood pressure was around 110/70 mmHg. No bradycardia was found. Body mass index was 16.4. No palpable thyroid swelling was found. There was no edema present. Examination of the systems including deep tendon reflexes was within normal limits.

On mental status examination, the patient was found to be conscious and alert, psychomotor activity was normal, talk was normal, mood was reported to be fine, and affect was anxious. He was also found to have second-person auditory hallucinations. He reported of hearing multiple male voices talking to him in Malayalam when he was awake. He could hear the voices throughout the day. He reported of clearly hearing the voices through his ears but would find no one around him when he heard them. He found these voices to be familiar and believed them to be of his coworkers. He reported that the voices spoke to him and asked him to do things. They did not speak among themselves or discuss about him.

Cognitive functions were intact. Insight – the patient was aware of having a psychiatric illness and attributed it to internal factors (Grade 3).

A provisional diagnosis of unspecified nonorganic psychosis was made, and the patient was admitted in the psychiatry ward for further assessment. Blood investigations including complete blood counts, thyroid function tests, renal function tests, liver functions tests, and blood glucose levels were done on admission.

Blood investigations revealed deranged thyroid function tests as follows:

Increased thyroid stimulating hormone (TSH) (350.4 uIU/ml) [Ref: 0.5-5uIU/ml]Decreased T3 (0.775 ng/ml) [Ref: 0.8–2 ng/ml]Decreased T4 (1.78 μg/dl) [Ref: 5–14 μg/dl]Decreased FT4 (0.282 ng/dl) [Ref: 0.8–1.8 ng/dl].

All other blood investigations were within normal limits. Electrocardiography done on admission was found to be normal.

Neuroimaging (computed tomography – brain) and ultrasound scan of the abdomen were also done which were found to be normal.

Endocrinology reference was given. The patient was diagnosed to have hypothyroidism and was started on tablet levothyroxine (100 μg). The patient was also started on an antipsychotic for symptomatic management. The patient showed improvement with the treatment. Hallucinations decreased within a week of onset of medications. The patient was discharged on antipsychotic and levothyroxine. A final diagnosis of organic hallucinosis (F06.0) and hypothyroidism was made.

On follow-up after 1 month, the patient reported that the hallucinations had completely stopped and that he had been able to resume going to work. Over a period of 2 months, the antipsychotic was tapered and stopped. The thyroid function tests were repeated again after 3 months and the values were as follows:

TSH – 124 Uiu/ML, T3 – 0.9 ng/ml, T4 – 9 μg/dl, and FT4 – 0.7 ng/dl.

 Discussion



The above-described case presented with psychiatric symptoms, but on evaluation was found to have a primary thyroid disorder. This emphasizes the need for detailed physical examination and evaluation for medical disorders in patients who present with psychiatric symptoms. In this case, at the outset, there was no history or clinical features suggestive of hypothyroidism. Only investigations revealed the hypothyroid state. This further enlightens the need for detailed laboratory investigation even in the absence of any obvious history or signs and symptoms of a medical disorder in a patient presenting with the first episode of psychiatric illness. Furthermore, in the absence of any past and family history of psychiatric illness, a detailed physical examination and diagnostic evaluation are all the more important, and a high index of suspicion should be present to rule out organic causes for psychiatric illness. Medical disorders presenting with psychiatric symptoms will often have absence of typical physical symptoms or might have an atypical presentation as in this case due to which there is high likelihood of missing the diagnosis unless thoroughly investigated. Hypothyroidism is a very much treatable condition and timely identification and treatment can help alleviate the patient's distress faster.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Bauer M, Goetz T, Glenn T, Whybrow PC. The thyroid-brain interaction in thyroid disorders and mood disorders. J Neuroendocrinol 2008;20:1101-14.
2Hall RC. Psychiatric effects of thyroid hormone disturbance. Psychosomatics 1983;24:7-11, 15-8.
3Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: Myxedema madness revisited. Prim Care Companion J Clin Psychiatry 2003;5:260-6.
4Lehrmann JA, Jain S. Myxedema psychosis with grade II hypothyroidism. Gen Hosp Psychiatry 2002;24:275-7.