Severe Hypothyroidism Presenting with Acute Mania and Psychosis: A Case Report and Literature Review

Abstract

Introduction: In patients presenting with acute mania and psychosis, it is important to rule out organic causes of their symptoms. Patients with severe hypothyroidism may present with psychosis and less commonly with symptoms of mania. We report a case of a 40 year old male presenting with acute mania and psychosis, in the context of severe hypothyroidism. Case presentation: A 40 year old Caucasian male presented to the emergency department with acute onset mania, and delusions of grandeur. One week prior to presentation, he demonstrated bizarre behavior and hyperactivity. On the day of admission, he sustained a self-inflicted burn on his left arm and left leg causing partial thickness burns. Blood work demonstrated elevated creatine kinase and creatinine, as well as profoundly high TSH (>100 uIU/L) and low thyroid hormones (T4=2 pmol/L, T3 1.9=pmol/L). He was medically diagnosed with rhabdomyolysis with acute kidney injury and severe hypothyroidism. He was started on antipsychotic medication (loxapine), a mood stabilizer (divalproex sodium) and levothyroxine. His psychosis and mania resolved after 2 weeks in hospital and TSH trended down (84.10 mIU/L) and free T4 (9 pmol/L) and free T3 (3.8 pmol) trended upwards. Conclusion: In patients presenting with severe hypothyroidism and acute mania with psychosis, treatment should include thyroid hormone replacement in addition to psychotropic medications.