SAT492 Hypothyroidism Induced Psychosis: A Rare Initial Presentation Of Severe Hypothyroidism

Abstract

Abstract Disclosure: M. Shaukat: None. M. Mack: None. E. Galarza: None. R. Saeed: None. L.E. Arzeno-Tejada: None. Introduction: Hypothyroidism presents as slowing of bodily functions that become more severe as the disease progresses. Common presentations of hypothyroidism are lethargy, constipation, hair and skin changes and mental slowing. We present a rare presentation of hypothyroidism induced psychosis, also called myxedema psychosis or more commonly, myxedema madness, triggered by lenalidomide. This, per our review, has only been reported a handful of times in prior literature. Case Description: 64-year-old male with a history of follicular Non-Hodgkins Lymphoma, currently on rituximab/lenalidomide who was brought to the Emergency Department (ED) for concerns of hallucinations, paranoia and manic episodes for three days. In the ED, his vitals were stable. Computed Tomography (CT) head was normal. Lab work revealed an elevated TSH at 51.70 uIU/ml (normal 0.30-5.0 uIU/ml), free T3 <0.1 pg/ml (normal 2.0-4.4 pg/ml) and free T4< 0.1 ng/dL(normal 0.7-1.7 ng/dL). Thyroid peroxidase antibody was 9 IU/ml (normal <34.0 IU/ml). He was started on intravenous levothyroxine and as needed haloperidol to which he responded well in about forty-eight hours. During this time, he got a MRI of his brain that was normal. He was examined by neurology who did not recommend any further neurological workup. He continued IV therapy for 4 weeks after which he was switched to oral levothyroxine. His chemotherapy regimen has been changed to bendamustine/rituximab and he was discharged to a psychiatric facility for two weeks. He continues to be on oral levothyroxine and is currently doing well. Discussion: Hypothyroidism is described as decreased activity of the thyroid gland that results in retardation in growth and development of children and adults and common initial presentations of hypothyroidism include lethargy, hair loss, skin changes, cold sensitivity, weight gain and constipation. The most common psychiatric association of hypothyroidism is depression. Studies have also shown that there is an association between hypothyroidism and bipolar disorders. Other psychiatric manifestations include loss of memory, labile emotions and forgetfulness. However, in around 5 to 15 percent of the patients, the initial presentation of hypothyroidism is psychosis, also termed myxedema psychosis. The exact mechanism is uncertain, and the evidence is based on experimental animal models, but it is believed that the effects on the brain are due to increased dopamine levels and tyrosine hydroxylase activity in hypothyroid patients, mostly in the limbic system where most emotional and behavioral responses are processed. Prompt diagnosis with thyroid function tests along with removal of the offending agent is important in these cases since the cause of psychosis is reversible and early treatment has promising results. Presentation Date: Saturday, June 17, 2023