Page 85 - JCBP-2-3

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

Hashimoto’s thyroiditis (5A03.20) and pituitary hyperplasia pertinent examinations. During the initial outpatient
secondary to hypothyroidism (5A61.Y). Subsequent consultation, this patient was exclusively treated with
follow-up assessments revealed a progressive amelioration antipsychotics and antidepressants for a period of 4 weeks.
in thyroid function and pituitary morphology, which led Nevertheless, her psychotic symptoms deteriorated under
to the remission of psychotic manifestations. The levels of this treatment regimen. Consequently, levothyroxine
thyroid-related antibodies exhibited a gradual decline but sodium replacement therapy was initiated in conjunction
did not attain the standard range. At that time, the patient with the same therapeutic dosage of antipsychotics
had achieved complete restoration of thyroid function, and antidepressants. As a result, the patient exhibited
and the dimensions and configuration of their pituitary significant improvement in psychotic symptoms alongside
gland had reverted to baseline. The maintenance therapy enhanced thyroid function, leading to complete remission.
of levothyroxine sodium was being continued, while the Furthermore, the lack of relapse post-discontinuation
medications lurasidone and sertraline were discontinued after of psychotropic medication suggests a strong correlation
6 months of initial treatment due to the absence of psychotic between thyroid hormone levels and the presentation of
symptoms. The final diagnosis, according to ICD-11, includes: psychotic symptoms. Given its prevalence as a causative
(1) 5A03.20: Hashimoto’s thyroiditis; (2) 6E61: secondary factor for psychiatric impairments in individuals with
psychotic syndrome-myxedema psychosis; and (3) 5A61.Y: Hashimoto’s thyroiditis, Hashimoto’s encephalopathy
other specified hypofunction or disorders of the pituitary assumes considerable importance as a crucial differential
gland-pituitary hyperplasia secondary to hypothyroidism diagnosis. Hashimoto’s encephalopathy typically presents
(PHPH). Table 1 presents the thyroid function and MRI with a range of neurological manifestations, including
results during treatment and follow-up, along with the ataxia, myoclonus, aphasia, tremor, seizures, and abnormal
corresponding thyroid hormone dosage. In addition, Figure 1 electroencephalography findings, which are observed
illustrates the changes in pituitary MRIs before and after in approximately 98% of patients. It is worth noting that
levothyroxine sodium replacement therapy. patients with this condition do not typically respond to
levothyroxine sodium replacement therapy but instead
3. Discussion show improvement when treated with steroid therapy. In
6
The initial treatment plan for the patient involved a 4-week this case, the patient displayed no clinical manifestations
regimen of combination therapy using antipsychotic and consistent with Hashimoto’s encephalopathy, had a normal
antidepressant medications. However, this period saw a electroencephalogram, and showed improvement after
deterioration of psychotic symptoms, characterized by receiving levothyroxine sodium replacement therapy.
delusions of victimization and a further decline in social As a result, the diagnostic criteria for Hashimoto’s
functioning. Given the patient’s condition, hospitalization encephalopathy were not fulfilled.
was considered a more advantageous approach to facilitate Subsequently, the patient’s psychiatric symptoms
thorough evaluations and determine a definitive diagnosis. were attributed to MP after excluding Hashimoto’s
The patient was admitted to the hospital and encephalopathy. The initial report of MP was documented
diagnosed with Hashimoto’s thyroiditis after undergoing by Asher in 1949, encompassing manifestations such

Table 1. Thyroid function, thyroid hormone doses, and MRI findings at diagnosis and during follow-up

Variable At diagnosis Time interval Last visit
3 m 6 m 12 m
TSH (mIU/L) a >100 >100 5.77 2.57 0.35
FT4 (pmol/L) b 1.70 9.90 16.3 20.2 21.6
FT3 (pmol/L) c 1.04 2.92 4.17 4.46 4.48
TGAb (IU/mL) d 333 274 - 279 -
TPOAb (IU/mL) e >600 529 - 525 -
TRAb (IU/L) f >40 >40 -
Thyroxine treatment (μg) 12.5 100 100 100 100
Pituitary MRI (cm) 1.4×1.4×1.5 - 0.9×0.8×0.9 Normal Normal
Notes: 0 – 115 IU/mL; 0 – 34 IU/mL; 0 – 1.75 IU/L.
f
e
d
Abbreviations: FT3: Free triiodothyronine; FT4: Free thyroxine; MRI: Magnetic resonance imaging; TGAb: Thyroglobulin antibody; TPOAb: Thyroid
peroxidase antibody; TRAb: Thyrotrophin receptor antibody; TSH: Thyroid-stimulating hormone.
Volume 2 Issue 3 (2024) 3 doi: 10.36922/jcbp.2317