Page 84 - JCBP-2-3

Journal of Clinical and
Basic Psychosomatics Hashimoto’s thyroiditis presenting psychotic symptoms

present with psychotic symptoms, such as delusions, A comprehensive clinical assessment demonstrated
changes in drive and activity, formal thought disorders, normal findings, with no abnormalities noted in the skin
and perceptual abnormalities. These symptoms may be or mucous membranes. The cranial nerves were intact,
misdiagnosed as schizophrenia. In addition, elevated showing no signs of dysfunction. The neck exhibited
1-4
levels of thyroid-stimulating hormone (TSH) in individuals normal flexibility without any evidence of rigidity.
with Hashimoto’s thyroiditis can lead to the proliferation Cardiopulmonary auscultation revealed unremarkable
of TSH-releasing cells, resulting in secondary pituitary results. There were no observed cases of limb edema, and
hyperplasia associated with primary hypothyroidism muscle strength and tone were maintained. Physiological
(PHPH). This rare complication of hypothyroidism, reflexes were within expected ranges, suggesting the
stemming from Hashimoto’s thyroiditis, poses difficulties absence of pathological signs. The psychiatric evaluation
in radiological assessments used to differentiate it from revealed intact consciousness, full orientation, the presence
pituitary adenoma. The atypical clinical presentations of of significant auditory hallucinations involving a group of
5
both MP and PHPH further complicate the diagnostic people commenting and criticizing the subject’s behaviors
process. and speech, delusions related to interpersonal interactions
and victimization, along with symptoms suggestive
2. Case presentation of depression. In accordance with the International
th
This case involves a 16-year-old female adolescent who Classification of Diseases 11 Revision (ICD-11), the initial
began experiencing symptoms of sensitivity and paranoia, diagnosis upon admission was 6A20.0: schizophrenia, first
accompanied by auditory hallucinations, approximately episode. Following the cranial magnetic resonance imaging
2 months before seeking medical consultation in the (MRI) scan, it was observed that the pituitary gland had
Department of Psychosomatic and Psychiatry, Zhongda enlarged, measuring 1.4 × 1.4 × 1.5 cm, and exhibited
Hospital, School of Medicine, Southeast University, superior protrusion with T1 high signal intensity in the
China. The patient perceived that her classmates at school neurohypophysis, indicating a high probability of pituitary
targeted her due to jealousy of her talents, manifesting adenoma. The assessment of thyroid function revealed
their animosity through behaviors such as coughing notably reduced levels of FT3 and FT4, accompanied by
and spitting. Subsequently, the patient reported hearing TSH levels surpassing 100 μIU/mL. Furthermore, there
multiple voices discussing her actions and predominantly was a significant elevation in thyroglobulin antibody,
criticizing her with malice. The hallucinations experienced thyroid peroxidase antibody (TPOAb), and thyrotrophin
by the patient were accompanied by a pervasive feeling of receptor antibody (TRAb). The thyroid ultrasonography
being under surveillance, resulting in increased levels of results revealed heterogeneous thyroid echogenicity with
anxiety and nervousness. It is noteworthy that the patient multiple nodules categorized as C-TI-RADS category 3.
did not attribute these symptoms to psychosis. Despite All measured parameters, including plasma cortisol, serum
persisting for a period of 2 months, the patient’s delusions prolactin levels, ACTH rhythm test results, and growth
and auditory hallucinations did not show obvious hormone measurements, fell within the normal range.
improvement. In addition, the patient displayed the Moreover, blood, urine, and stool analyses, along with
onset of depressive symptoms, such as a depressed mood, biochemical indices, as well as electrocardiogram and
reduced interest and pleasure, decreased appetite, and electroencephalogram examinations, exhibited no
insomnia. Consequently, the individual’s parents sought abnormalities. In addition, both the humoral immune-
medical intervention for her condition. specific protein tests and the 13-item antinuclear antibody
The psychiatrist in the outpatient unit thoroughly panel did not detect any anomalies.
evaluated the potential diagnosis of schizophrenia, In light of the findings described above, the
considering the lack of pre-existing psychiatric or chronic endocrinologist considered Hashimoto’s thyroiditis as
medical conditions, as well as the absence of any history the potential diagnosis and recommended the initiation
of substance abuse. Despite receiving consistent outpatient of levothyroxine sodium replacement therapy without
care with lurasidone (40 mg/day) and sertraline (50 mg/ adjusting the dosages of lurasidone and sertraline. After
day) for the past 4 weeks, the patient did not manifest 4 weeks of treatment, the patient showed improvement in
improvement in psychotic symptoms. In addition, new both psychiatric symptoms and thyroid function, which
symptoms have emerged, such as a heightened perception led to a decision to discharge the patient from medical
of public surveillance and home monitoring through care through mutual agreement between the patient and
electronic devices. These symptoms significantly hindered psychiatrist. In accordance with the ICD-11, the discharge
her ability to engage in academic pursuits, resulting in her diagnosis encompassed the following: (1) 6E61: Secondary
admission as an inpatient. psychotic syndrome? The patient initially presented with

Volume 2 Issue 3 (2024) 2 doi: 10.36922/jcbp.2317