Asymptomatic hyperthyroidism progressing to thyroid storm manifesting as organic mood disorder with secondary encephalopathy: A case report
Keywords:
Thyroid storm, hyperthyroidism, psychosis, mood lability, organicAbstract
Thyroid storm is a rare but life-threatening endocrine emergency, often precipitated by untreated or poorly managed hyperthyroidism. Psychiatric manifestations, including psychosis and mood lability, can obscure the diagnosis, particularly in patients without prior thyroid symptoms and history. In this article, we present an unusual case where psychosis and mood lability were the initial symptoms of thyroid storm. Case Presentation, we reported a case of a 24-year-old male with no symptoms of hyperthyroidism or prior medical and psychiatric history, admitted to the emergency department with signs of psychosis and mood lability. There was no significant improvement in behaviour disturbances during hospitalization. After 6 days of observation, his condition worsened, and further workup revealed overt hyperthyroidism. Assessment on the Burch-Wartofsky Point Scale (BWPS) and Japanese Thyroid Association (JTA) scale also revealed highly suggestive of thyroid storm. After intensive thyroid storm management, his condition was improved, but two days later, a seizure occurred as an indication of secondary encephalopathy. Therefore, this patient was referred to an advanced hospital for further workups and intensive care treatment. Discussion, this case highlights the diagnostic challenge of thyroid storm presenting primarily with psychiatric symptoms in an individual with no prior history of thyroid or psychiatric illness. Thyrotoxicosis can mimic psychosis or mood disorders, leading to delayed recognition and treatment. Early identification and a multidisciplinary approach are crucial to prevent morbidity and mortality of thyroid storm. Conclusion, the diagnosis of psychiatric disorder should only be established after other possible organic causes have been excluded. Physicians should be cautious and suspicious of thyroid dysfunction or any endocrine disorder in patients presenting with acute psychiatric symptoms, even in the absence of classical hyperthyroid signs
References
Ursem SR, Boelen A, Bruinstroop E, et al. (2024) A systematic review of subclinical hyperthyroidism guidelines: a remarkable range of recommendations. Eur Thyroid J, 13(1). https://doi.org/10.1530/ETJ-24-0036.
Ross DS, Burch HB, Cooper DS, et al. (2016). American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid, (26): 1343–1421.
De Almeida R, McCalmon S, Cabandugama PK. (2022). Clinical review and update on the management of thyroid storm. Mo Med, 119: 366–371.
Kahaly GJ, Bartalena L, Hegedüs L, et al. (2018) European Thyroid Association guideline for the management of Graves’ hyperthyroidism. Eur Thyroid J, 7: 167–186.
Thiyagarajan A, Platzbecker K, Ittermann T, et al. (2022) Estimating incidence and case fatality of thyroid storm in Germany between 2007 and 2017: A claims data analysis. Thyroid, 32: 1307–1315.
Bindu Nayak KB. (2006). Thyrotoxicosis and thyroid storm. Endocrinology and Metabolism Clinics of North America, (35): 663–686.
Bunevicius R, Prange AJ Jr. (2010). Thyroid disease and mental disorders: cause and effect or only comorbidity. Curr Opin Psychiatry, (23): 363–368.
Bunevicius R, Prange AJ. (2012). Psychiatric manifestations of Graves’ hyperthyroidism. CNS Drugs, 20: 897–909.
Substance Abuse and Mental Health Services Administration. (2016). Impact of the DSM-IV to DSM-5 changes on the national survey on drug use and health. In: Center for Behavioral Health Statistics and Quality (CBHSQ), Substance Abuse and Mental Health Services Administration (SAMHSA). U.S. Department of Health and Human Services, 2016.
Calabrese JR, Gao K, Sachs G. Diagnosing Mania in the Age of DSM-5. (2017). American Journal of Psychiatry, 1 https://doi.org/ 10.1176/appi.ajp.2016.16091084.
Major depressive disorder. (2020). In: Functional Analysis in Clinical Treatment. Academic Press.
World Health Organization. International statistical classification of diseases and related health problems 5th edition. WHO Library Cataloguing, 2011.
Papi G, Pontecorvi A. (2019). Editorial: The Unusual Presentation of Thyroid Disorders. Front Endocrinol (Lausanne), 10: 560.
Akamizu T, Satoh T, Isozaki O, et al. (2012). Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid, https://doi.org/ 10.1089/thy.2011.0334.
Govindani R, Gavli J, Pratap Singh D, et al. (2024). Chronos and crisis: The dangers of delayed treatment in thyroid storm: A case series. Inter J Sci Res, 21–24.
Kravets I. (2016). Hyperthyroidism: Diagnosis and treatment. Am Fam Physician, 93: 363–370.
Gulseren S, Gulseren L, Hekimsoy Z, Cetinay P, Ozen C, Tokatlioglu B. (2006). Depression, anxiety, health-related quality of life, and disability in patients with overt and subclinical thyroid dysfunction. Arch Med Res, 37: 133–139.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R). 5th ed. Arlington, TX: American Psychiatric Association Publishing.
Kementerian Kesehatan Republik Indonesia. (2015). Pedoman Nasional Pelayanan Kedekteran Jiwa. HK.02.02/MENKES/73/2015, Kementerian Kesehatan Republik Indonesia. http://hukor.kemkes.go.id/ uploads/ produk hukum.
Asif H, Nwachukwu I, Khan A, et al. (2022). Hyperthyroidism presenting with mania and psychosis: A case report. Cureus, (14): e22322.
Ressler HW, Shah K, Quattlebaum T, et al. (2023). Catatonia and psychosis associated with hyperthyroidism. Prim Care Companion CNS Disord, 25. 2023. https://doi.org/10.4088/PCC.23cr03554.
Kankpeyeng HB, Iroko D, Dordoye E, et al. (2022). Thyroid psychosis in a young male: an unusual presentation of Graves’ disease (a case report). (2019). PAMJ Clinical Medicine; 9. DOI: 10.11604/pamj-cm.2022.9.9.29242.
Adiba A. Association of thyrotoxicosis with mania. Am J Psychiatry Resid J, 14: 8–10.
Ishihara Y, Sugawa T, Kaneko H, et al. (2019). The delayed diagnosis of thyroid storm in patients with psychosis. Intern Med Japan, 58: 2195–2199.
Fukui T, Hasegawa Y, Takenaka H. (2001). Hyperthyroid dementia: clinicoradiological findings and response to treatment. J Neurol Sci, 184: 81–88.
Prabhu H, Jagdish TK, Valdiya PS, et al. (1994). Grave’s disease with organic mood syndrome (A case report). Med J Armed Forces India, 50: 219–220.
Chiera M, Draghetti S, De Ronchi D, et al. (2023). Hyperthyroidism and depression: a clinical case of atypical thyrotoxicosis manifestation. Int Clin Psychopharmacol, 38: 269–272.
Bauer M, Goetz T, Glenn T, et al. (2008). The thyroid-brain interaction in thyroid disorders and mood disorders. J Neuroendocrinol, 20: 1101–1114.
Akamizu T. Thyroid Storm: A Japanese Perspective. Thyroid, 28: 32–40.
Fliers E, Bianco AC, Langouche L, et al. (2015). Thyroid function in critically ill patients. Lancet Diabetes Endocrinol, 3: 816–825.
Satoh T, Isozaki O, Suzuki A, et al. (2016). Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J, 63: 1025–1064.
Abdi H, Amouzegar A, Azizi F. (2019). Antithyroid Drugs. Iran J Pharm Res, 2019; 18: 1–12.
Endo M. Can methimazole replace propylthiouracil in the treatment of thyroid storm. Clinical Thyroidology 2023. https://doi.org/ 10.1089/ct.2023;35.229-231.
Lee SY, Modzelewski KL, Law AC, et al. (2023). Comparison of propylthiouracil vs methimazole for thyroid storm in critically ill patients. JAMA Netw Open, 6: e238655.
Suzuki N, Noh JY, Hiruma M, et al. (2019). Analysis of antithyroid drug-induced severe liver injury in 18,558 newly diagnosed patients with Graves’ disease in Japan. Thyroid, 29: 1390–1398.
Dalan R, Leow M. (2007). Cardiovascular Collapse Associated with Beta Blockade in Thyroid Storm. Exp Clin Endocrinol Diabetes, 115: 392–396.
De Groot LJ, Bartalena L, Feingold KR. (2025). Thyroid Storm. In: Endotext [Internet]. MDText.com, Inc.
Alshamsi F, Belley-Cote E, Cook D, et al. (2016). Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Critical Care, 20: 1–12.
Caplan A, Fett N, Rosenbach M, et al. (2017). Prevention and management of glucocorticoid-induced side effects: A comprehensive review: Ocular, cardiovascular, muscular, and psychiatric side effects and issues unique to pediatric patients. J Am Acad Dermatol, 76: 201–207.
Bennett B, Mansingh A, Fenton C, et al. (2021). Graves’ disease presenting with hypomania and paranoia to the acute psychiatry service. BMJ Case Rep, 14. https://doi.org/10.1136/bcr-2020-236089.
Golub D, Rodack V. (2018). Antipsychotics in hyperthyroid-related psychosis: Case report and systematic review. Neuro Endocrinol Lett, 39: 65–74.
Urias-Uribe L, Valdez-Solis E, González-Milán C, et al. (2017). Psychosis crisis associated with thyrotoxicosis due to Graves’ disease. Case Rep Psychiatry, 6803682.
Kothari S, Townsend W, Chaudhry Z, et al. (2023). Psychosis secondary to thyrotoxicosis that persisted post-thyroidectomy: a case report. BMC Psychiatry, 23: 750.
Iversen T, Steen NE, Birkeland KI, et al. T229. (2018). Antipsychotic drug use and thyroid function in patients with severe mental disorders. Schizophr Bull , 44: S205–S206.
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