Case Presentation:
A 53-year-old female with significant history of depression, epilepsy, and osteoporosis is brought to the ED by her husband for suicidal ideation. She reports that over the last 3 months she has had increasing symptoms of depression, anxiety, and mood swings and for the last 2 weeks has had intermittent thoughts of suicide with a plan to ingest multiple pills. She does have a history of suicide attempt about 20 years ago but depression has been in excellent control without medication for many years. She also reports developing tremor, lightheadedness with standing, and increased anxiety 2 days ago. Seizures have been well controlled recently with levatiracetam.
Physical exam reveals tachycardia, a non-enlarged but rubbery thyroid, a 3/6 systolic murmur, bilateral lower extremity non-pitting edema, a coarse bilateral hand tremor, pressured speech, and a flat affect. Lab work is significant for a TSH of 0.0 uIU/mL, Free T4 2.6 ng/dL, Total T3 of 6.32 ng/mL, and Free T3 of 23.1 pg/mL. Subsequent work up reveals a positive TSH receptor antibody level of 21 IU/L consistent with Graves Disease. She is started on methimazole, citalopram, and propranolol and shows significant improvement in mood, tremor, and anxiety and is able to discharge home following evaluation by psychiatry.
Discussion:
The presentation of Grave’s Disease can be varied as symptoms can affect multiple organ systems. Psychiatric symptoms of depression and anxiety are well documented associations to hyperthyroidism however suicidal ideation with thyrotoxicosis is rare in the literature. This patient’s depression symptoms responded rapidly to treatment of the thyrotoxicosis, indicating that her presenting complaints were most likely due to the endocrine derangement.
Conclusions:
Suicidal ideation is a common presentation of patients with a history of depression but it is important to rule out medical etiologies for these symptoms as well. A complete history and physical exam may lead to clues for alternative diagnosis as it did for this patient.