Steroid-Induced Psychosis Treated With Valproic Acid and Risperidone in a Patient With Systemic Lupus Erythematosus

Abstract

Sir: Multiple endocrine and nutritional disorders are characterized by neuropsychiatric manifestations. Psychiatric symptoms have been reported in thyroid, parathyroid, adrenal, and pituitary disorders. 1 We present a case of a young man with a recent diagnosis of Graves disease and onset of acute psychotic symptoms. 2,3Case report. Mr. A, a 25-year-old man, was brought to the emergency department by a friend in January 2004. During evaluation at the emergency department, he was reported as alert and oriented to place and person. He appeared very scared and complained of visual and auditory hallucinations. With these complaints he was admitted to the psychiatric unit for further care.During inpatient evaluation, Mr. A reported that he had experienced sudden onset of visual hallucinations 1 month earlier. He described the visual hallucinations as a face covered with a white mask that appeared in front of him from time to time. He reported that the face also talked to him and that he heard a male voice telling him that he would be harmed. He reported that he felt that his house was possessed by demons and that they were coming to get him. He reported getting suspicious of his family members and thought that someone was doing witchcraft on him. Mr. A reported that he had moved out of his house to a friend's residence hoping these visions and voices would go away. His symptoms continued to occur, and thus he was brought to the emergency department by his friend.During evaluation, Mr. A denied having any history of psychotic symptoms or psychiatric treatment. He stated that he had a history of learning disability in reading and mathematics, which had been diagnosed in middle school. He reported attending special education classes until the 10th grade. No history of psychotropic medications was specified by Mr. A. He denied having any history of recent or past alcohol or drug abuse. Collateral information concurred with Mr. A's history.During inpatient psychiatric treatment, Mr. A was started on risperidone, 1 mg twice daily. Physical examination revealed bilateral proptosis with diplopia on superior and lateral gaze. Minimal lid lag was also noted. Conjunctival injection was noted bilaterally with no ulceration. His thyroid gland was visibly and palpably enlarged approximately 3-fold and was smooth, symmetrical, and nontender. A bruit was noted on the right lobe of the thyroid gland. Other aspects of his physical examination were noncontributory.Mr. A reported that he had received a diagnosis of Graves disease 3 months before this hospitalization. He reported that he was started on treatment with propranolol and that he had been noncompliant with his medications and follow-up with his endocrinologist. He reported weight loss of 20 to 25 lb over a 2-month period. His medical workup obtained from his endocrinologist included a thyroid uptake scan study showing markedly elevated thyroid uptake and compatible findings of Graves disease. His medications included metoprolol extended release, 50 mg p.o. q.d. During his las...

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