Manic symptoms in the context of anti-thyroid antibodies and letrozole infertility treatment

Abstract

A woman in her mid-30s presented to the emergency department upon the recommendation of her obstetrician with manic symptoms after four months of letrozole infertility treatment. Her history of present illness included irritability and increased energy for three weeks. On examination she exhibited distractibility, pressured speech, racing thoughts, and hypergraphia, all of which she noted to be present for at least the past week. Her medical history is significant for Hashimoto’s thyroiditis, stabilized with levothyroxine 50 mcg daily, and unspecified depression, for which she has not required treatment in more than five years. Brain computed tomography and thyroid panel revealed normal imaging and normal thyroid stimulating hormone levels, respectively. Thyroid antibody titers were not measured in the emergency department. Syphilis test was negative. She was subsequently admitted for stabilization and accepted risperidone therapy. Manic symptoms started to subside within 48 hours of admission. After some symptom improvement she decided to leave against medical advice with instructions to follow-up with her primary care physician. Upon later referral to an autoimmune neurologist, her thyroid peroxidase antibody level measured high, which was concerning for Hashimoto encephalopathy. EEG showed no abnormalities and corticosteroids were not administered. The patient was tapered off risperidone in the following months with no manic symptom recurrence to date.