Case Presentation: We present a case of a 26-year-old male with a past medical history of hyperthyroidism who presented with altered mental status after being found at a store with bizarre behavior. On arrival, he was awake, alert with tangential speech. The patient was slow and deliberate in responding to questions. He complained of poor sleep, appetite, and dizziness. He noted he was previously on methimazole, stopped by his outpatient endocrinologist. He worked as an Uber driver, spending most nights up and sleeping during the day. He was honorably discharged from the military and served in the police force. He denied any substance abuse. Vitals were notable for blood pressure 167/101, heart rate 122, and respiratory rate 22. He appeared flushed. No exophthalmos, thyroid tenderness, or palpable nodule present. Labs notable for TSH 0.009 (0.3-4.0), Free T4 6.0 (0.8-1.4), T3 387 (83-183), and TSI 471 (<140). The patient was started on methimazole, propranolol, potassium iodide, and hydrocortisone. Throughout his hospital course, the patient continued to remain very energized, restless, impulsive, and very labile in mood and behavior. He was awake at night, gaming on his phone and dancing to music throughout the night. He had not slept in 48-72hrs and developed auditory hallucinations with paranoid delusions. Neurology was consulted to rule out any organic cause of his psychosis- EEG showed no epileptiform activity, MRI brain- no acute intracranial abnormalities. Psychiatry started the patient on Olanzapine, which did help him sleep, but he continued with psychotic manifestations. He denied any suicidal or homicidal ideations. It was determined that this was an atypical presentation of Thyroid Storm.
Discussion: The cause of acute psychosis in young adults can have a broad differential diagnosis, including psychological causes such as schizophrenia, bipolar disorder, depression, or organic causes such as infectious etiologies, metabolic, brain tumors, and substance abuse. We have known that hypothyroidism can be associated with psychosis [1], but it is rare for psychosis to be a complication of hyperthyroidism [2]. Thyroid Storm is characterized by severe clinical manifestations of thyrotoxicosis, including fever, tachycardia, gastrointestinal symptoms, and central nervous system manifestations including anxiety, agitation, mania, psychosis, seizures, and coma. The most common etiology is Graves’ Disease, as seen in our patient, although other precipitants include thyroid or non-thyroid surgery, infection, trauma, occasional use, or discontinuation of antithyroid drugs. It is hypothesized that neuropsychiatric derangements involve excess thyroid hormones affecting dopamine and serotonin neurotransmission. Rarely described in the literature are cases of psychosis as the presenting feature of thyroid storm, an atypical presentation as in our patient. In a case series of 28 patients with neuropsychiatric derangements in thyrotoxicosis, it was noted that CNS involvement was less frequent, but statistically associated with mortality [3].
Conclusions: Though psychosis is a relatively common presentation in medicine, clinicians should be vigilant of organic causes of psychoses in their practice including thyrotoxicosis, as patients may have morbidity and mortality benefit with early medical management.