Hypothyroidism is a common hormone deficiency, associated with multiple causes and presenting with diverse clinical manifestations including neuropsychiatric disease. Hypothyroidism is commonly associated with depressive symptoms, and thyroid hormone screening is indicated in patients with a history of depression. Although other neuropsychiatric disorders could be induced by hypothyroidism, only 14 reports present clinical cases of mania related with this hormone deficiency.1,2 Autoimmune thyroiditis is the most frequent reported cause of hypothyroidism associated with acute mania. Here we present a clinical case of acute mania in a 36-year-old man with hypothyroidism resulting from thyroidectomy in the context of papillary thyroid carcinoma.(undefined)info:eu-repo/semantics/publishedVersio

Gonçalves, Carla Marina Mendonça

Morgado, Pedro

Journal of Neuropsychiatry

Universidade do Minho: RepositoriUM

Acute Mania Induced by Hypothyroidismin a Male Patient After ThyroidectomyTo the Editor: Hypothyroidism is a common hormone de-ﬁciency, associatedwithmultiple causes and presentingwithdiverse clinical manifestations including neuropsychiatricdisease. Hypothyroidism is commonly associated with de-pressive symptoms, and thyroid hormone screening is in-dicated in patients with a history of depression. Althoughother neuropsychiatric disorders could be induced by hy-pothyroidism, only 14 reports present clinical cases of maniarelated with this hormone deﬁciency.1,2 Autoimmune thy-roiditis is themost frequent reported cause of hypothyroidismassociated with acute mania. Here we present a clinical caseof acute mania in a 36-year-old man with hypothyroidism re-sulting from thyroidectomy in the context of papillary thyroidcarcinoma.Case ReportA 36-year-old man with no past or family history of psychi-atric illness was brought to the psychiatric emergency roomfor disruptive behavior associated with auditory and visualhallucinations andmystic delusions. Hewore a blindfold overhis eyes and a large cross at his neck, believing that anyonewho looked at his eyes would become blind. According to hisfamily, symptoms began suddenly 2 days before arrival to thehospital. On examination, he was conscious and his orienta-tion was intact. He manifested high distractibility, elevatedand expansive mood, pressure of speech, ﬂight of ideas, ex-periences of self-reference, and mystic delusions. Physicalexamination revealed myxedema. Results on physical andneurological examinations were otherwise normal.He had a previous history of papillary thyroid carcinomaand had undergone thyroidectomy and radioactive iodinetherapy 4 months before arrival to the hospital. After sur-gery, he started taking levothyroxine for 2 months but hadstopped 2 months before arrival to the hospital because hemisunderstood the information.Initial laboratory assessment (including complete bloodcount, electrolytes, and renal and liver function) was withinnormal values. Results onurine drug screen testwere negative,and blood ethanol levels were undetectable. Electrocardio-gram resultswere normal, and results on brainCT scan did notdemonstrate any pathology. His free levothyroxine (fT4) levelwas low at 0.55 ng/dL (0.76–1.46 ng/dL), and his thyroid-stimulating hormone (TSH) level was elevated at 98.1 uIU/mL(0.36–3.74 uIU/mL). Thyroid peroxidase and thyroglobulinantibodies titer resultswere negative. Prolactin levelwaswithinnormal range.After the initial evaluation, a diagnosis of acutemania wasestablished and he was admitted to the Hospital de Braga’sPsychiatry Unit. The patient was medicated with olanzapine15 mg/day and lorazepam 5 mg/day to treat his psychoticmania and was prescribed levothyroxine 100 mg/day totreat his hypothyroidism. His manic symptoms improvedrapidly, and he was discharged from the hospital 2 weekslater in a clinically stable condition and demonstrated im-provements in serum levels of fT4 (0.70 ng/dL) and TSH(82.7 uIU/mL).After the patient was discharged, olanzapine was pro-gressively reduced until complete discontinuation at 6months. With levothyroxine maintenance therapy, thyroidfunction returned to normal levels (fT4: 0.82 ng/dL, TSH:0.55 uIU/mL). Despite taking no psychotropic medication,the patient showed no psychiatric symptoms after a 2-yearfollow-up.DiscussionThe association between thyroid disorders and affectivedisorders has been well documented for more than a cen-tury. Typically, hypothyroidism is associated with depres-sion and hyperthyroidism with mania. The occurrence ofmania in hypothyroid states is rare, and only a few cases ofmania associated with hypothyroidism have been reportedin the literature. Characteristically, these patients werewomen (12 of 14) and had no previous psychiatric history (9of 14), and autoimmune thyroiditis was identiﬁed as thelikely cause of hypothyroidism in most cases.1,2Our patient reported here manifested unusual featuresof acute mania associated with hypothyroidism: the patientwas male, the hypothyroidism resulted from a thyroidec-tomy due to a papillary thyroid carcinoma, and there was nohistory of autoimmune thyroiditis. These facts highlight theimportance of determining whether the mania displayed inour patient was a primary psychiatric disorder or secondaryto documented hypothyroidism.First, our patient had no previous personal or family his-tory of mental illness, alcohol use, and/or drug abuse. Second,he had an atypical age for the onset of bipolar mania: bipolardisorder has a mean age of onset of 22 years, and symptomsmay occur even earlier.3 Third, he had visual hallucina-tions—an uncommon symptom in bipolar mania.4 Fourth, hispsychotic symptoms improved rapidly after antipsychotictreatment and levothyroxine supplementation for 2 weeks.J Neuropsychiatry Clin Neurosci 28:1, Winter 2016 neuro.psychiatryonline.org e21LETTERSFinally, he had neither recurrence of mania nor episodesof depression or psychosis during the 2-year follow-upwithout any psychiatric medication. Altogether, thesefacts support the diagnosis of a psychotic mania second-ary to hypothyroidism.Brain mechanisms involved in acute mania associatedwith hypothyroidism are unknown. However, several hy-potheses have been postulated, including increased tyrosinehydroxylase activity with subsequent increased cerebraldopamine levels, increased catecholamine activity inducedby higher sensitivity of beta adrenergic receptors, disruptionof circadian rhythms, and direct action of thyroid peroxidaseantibodies.1 The lack of sleep disturbances before maniaonset and the absence of antithyroid and antithyroglobulinantibodies in our patient make the latter two mechanismsless likely to explain his psychotic mania.The psychiatric manifestations of hypothyroidism arevery diverse and include cognitive, affective, and psychoticsymptoms. Despite being a rare presentation of hypo-thyroidism, patients who manifest atypical mania shouldbe screened for thyroid disease for prompt recognitionand management of possible underlying endocrinologicalpathology.REFERENCES1. Khemka D, Ali JA, Koch CA: Primary hypothyroidism associated withacute mania: case series and literature review. Exp Clin EndocrinolDiabetes 2011; 119:513–5172. Lin CL, Yang SN, Shiah IS: Acute mania in a patient with hypo-thyroidism resulting from Hashimoto’s thyroiditis. Gen Hosp Psy-chiatry 2013; 35:683.e1–683.e23. Hirschfeld RM: Differential diagnosis of bipolar disorder and majordepressive disorder. J Affect Disord 2014; 169(Suppl 1):S12–S164. Waters F, Collerton D, Ffytche DH, et al: Visual hallucinations in thepsychosis spectrum and comparative information from neurodegen-erative disorders and eye disease. Schizophr Bull 2014; 40(Suppl 4):S233–S245Pedro Morgado, M.D., Ph.D.Marina Mendonça-Gonçalves, M.D.Life and Health Sciences Research Institute (ICVS), School of Health Sciences,University of Minho, Braga, Portugal (PM, MM-G); ICVS-3Bs PT GovernmentAssociate Laboratory, Braga/Guimarães, Portugal (PM, MM-G); and Hospitalde Braga, Braga, Portugal (PM).Send correspondence to Dr. Morgado; E-mail: pedromorgado@ecsaude.uminho.ptA signed informed consent was obtained from the patient.The authors report no ﬁnancial relationships with commercial interests.Received Sept. 8, 2015; accepted Sept. 10, 2015.J Neuropsychiatry Clin Neurosci 2016; 28:e21–e22; doi: 10.1176/appi.neuropsych.15090219e22 neuro.psychiatryonline.org J Neuropsychiatry Clin Neurosci 28:1, Winter 2016LETTERS

Acute mania induced by hypothyroidism in a male patient after thyroidectomy

Pedro Morgado

Marina Mendonça-Gonçalves

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Acute Mania Induced by Hypothyroidism in a Male Patient After Thyroidectomy

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Acute mania induced by hypothyroidism in a male patient after thyroidectomy

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