Myxoedema madness

Abstract

A 59-year-old man was referred for Mental Health Act Assessment following several months of 'odd behaviour' and self-neglect reported by his neighbours. He presented as unkempt and expressed delusional ideas with respect to age, employment and identity of family members. He was fully oriented but lacked insight into his mental state and capacity for self-care. Physical examination revealed dry skin and slow relaxing reflexes. Blood investigations revealed a raised thyroid stimulating hormone and free T4 with positive thyroid peroxidise antibodies. MRI of the brain revealed frontal lobe and cerebellar atrophy, while neuropsychological assessment identified deficit in memory processing and executive functions. Despite appropriate correction of primary hypothyroidism with levothyroxine, the patient remained delusional with respect to age and employment although he showed some improvement in memory. Capacity for self-care remained poor; thus, he was eventually transferred to sheltered housing with rehabilitation.

Acute psychosis and concurrent rhabdomyolysis unveiling diagnosis of hypothyroidism

“…This, in part, may explain the partial or non-response of the remaining patients. Other possible causes for non-response to thyroid treatment are coexisting primary psychiatric disease or a long-standing disease where chronic metabolic changes have led to irreversible brain damage; Azzopardi et al also described the latter 7…”

Cerebral amyloid angiopathy presenting with neuropsychiatric symptoms

“…The reported time to recovery is quite variable but may be more dependent on the duration of hypothyroidism and may take months (Azzopardi et al, 2010). So we would suggest that rapid thyroid normalisation is only warranted if medically indicated.…”

“…This clinical scenario reflects the association between hypothyroidism and psychosis described by Asher in 1949 and termed 'myxoedema madness' (Azzopardi et al, 2010). Animal studies suggest a rise in cerebral dopamine with increased tyrosine hydroxylase activity as a potential aetiology.…”

Iatrogenic hypothyroidism and acute psychosis

“…While it is widely accepted that hypothyroidism can cause depressive symptoms, to the best of our knowledge only a few cases of psychotic symptoms associated with this condition have been described [3,[5][6][7][8][9][10]. Based on the patient's clinical history, on the rapid onset and remission of symptoms and on the doses of medication that were prescribed ( Table 1), as well as the lab values (Tables 2 and 3), we hypothesize that our patient's psychotic episode was caused by iatrogenic hypothyroidism.…”