PSAT334 An Unusual Case of Thyroid Storm in a Patient with Schizophrenia-A Diagnostic Dilemma

Abstract

Abstract Introduction Thyroid storm represents life threatening endocrine disorder that requires early recognition and treatment due to significant mortality rates. Case reports in which diagnosis of thyroid storm was delayed secondary to acute psychotic symptoms mainly consisting of auditory hallucinations, delusions, and violent behavior have been published. This case serves to illustrates that even in patients with schizophrenia acute psychiatric disorder can be early manifestation of life-threatening endocrine disorder. Clinical case We present a case of 25-year-old male with history of schizophrenia who was brought to hospital after he was found down, disoriented, with auditory hallucinations. Associated symptoms included diarrhea and abdominal pain. On physical exam patient was found to have altered mental status, proptosis, tachycardia, diaphoresis, and warm and moist skin. Due to suspicion for worsening schizophrenia patient was evaluated by psychiatry and was found to have active suicidal ideation. Thyroid function tests (TFTs) was significant of elevated fT4 and T3 (fT4 > 5.0 ng/dl, T3 6.5 ng/dl) and suppressed TSH (0.020 µIU/ml). Burch-Wartofsky Point Scale was suggestive of impending thyroid storm and endocrinology was consulted after which treatment with methimazole, dexamethasone, propranolol, and potassium iodide (Lugol's solution) was started. On second day of treatment patient had significant improvement in mental status with resolution of auditory hallucination, suicidal ideation, and tachycardia with complete return to his baseline mental status on the third day of hospital stay. At the end of hospital course TFTs also showed decrease in fT4 and T3 and patient was discharged on methimazole and propranolol as well as paliperidone for treatment of schizophrenia. When patient was seen during outpatient follow-up, he was free of any psychiatric symptoms. Conclusion Mental status changes due to thyroid storm versus acute worsening of schizophrenia is hard to differentiate. Our case shows that even in the patients with prior psychiatric history, thyroid storm should be highly on differential diagnosis especially when patients are presenting with acute worsening of symptoms. In this case high suspicion for thyroid storm and early treatment in first 24h of the presentation lead to favorable outcome of this life-threatening condition. As thyroid storm is clinical diagnosis, high suspicion, use of Burch-Wartofsky Point Scale and early measurement of TFTs can help physicians distinguish thyroid storm from primary neuropsychiatric presentation. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.