Page 86 - JCBP-2-3

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

A B edema and approximately 26 – 37% exhibited no somatic
symptoms. This lack of typical symptoms can potentially
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lead to misdiagnosis.
The patient’s MRI revealed an enlarged pituitary
gland, suggesting a pituitary adenoma. Among
adenomas, prolactinomas represent the most prevalent
type, characterized by elevated prolactin (PRL) levels
(>200 ng/mL). Patients with pituitary prolactin adenomas
may present with hypothyroidism, but their TSH levels
remain unaltered despite reduced plasma FT3, FT4, T3,
and T4. In this particular instance, the patient exhibited
normal PRL levels yet displayed notably elevated TSH levels
C D
in conjunction with heightened TPOAb and TRAb levels.
The thyroid ultrasonography revealed heterogeneous
echogenicity and the presence of multiple nodules.
Consequently, these current findings strongly suggest
that the abnormal thyroid function is more indicative
of hypothyroidism caused by Hashimoto’s thyroiditis.
After the initiation of levothyroxine sodium replacement
therapy, a progressive normalization of pituitary size was
observed in conjunction with enhanced thyroid function,
providing additional evidence of a significant relationship
between pituitary hyperplasia and Hashimoto’s thyroiditis.
The enlargement of the pituitary gland may be linked
Figure 1. Sagittal brain magnetic resonance imaging (MRI) in patients to primary hypothyroidism as a rare complication of
before and after treatment. (A) Pre-treatment pituitary MRI scan with
contrast enhancement. (B) Pituitary MRI scan with contrast enhancement Hashimoto’s thyroiditis.
after 6 months of levothyroxine sodium replacement therapy. (C) Pituitary The initial diagnostic imaging report indicated the
MRI scan with contrast enhancement after 1 year of treatment. (D) MRI
scan of the pituitary gland during the final visit. potential presence of pituitary adenoma in our patient;
nevertheless, we cast doubt on this diagnosis based on
as delusions, visual and auditory hallucinations, their neuroendocrine findings. Subsequent follow-up
loose associations, and paranoia. Despite significant and administration of levothyroxine sodium replacement
7
advancements in our understanding of hypothyroidism therapy ultimately confirmed the inaccuracy of the initial
diagnostics and treatment, our knowledge regarding diagnosis of pituitary adenoma. The enlarged pituitary
the optimal management strategies for patients with MP gland should be regarded as PHPH based on the patient’s
has stopped expanding since Asher first described the imaging, endocrine examination, and treatment follow-up
proper treatments for this group of patients. At present, findings. Adult PHPH was first recognized by Niepce in
the complete understanding of the pathophysiological 1851, and similar cases were subsequently reported, but it is
mechanisms linking MP and Hashimoto’s thyroiditis uncommon in children, with only relevant 18 cases reported
remains elusive. Potential factors contributing to this thus far. MRI findings of PHPH typically show an enlarged
association include dysregulation of tyrosine hydroxylase pituitary gland with prominent uniform enhancement on
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in the anterior lobe of the blue-spot, upregulation of T3 scans. Hashimoto’s thyroiditis is the most common cause
receptors in the amygdala and hippocampus, disturbances of hypothyroidism in children and adolescents. PHPH
in serotonin-mediated neurotransmission, as well as is a consequence of reduced thyroid hormone levels in
compromised regional cerebral blood flow and glucose hypothyroidism, resulting in diminished negative feedback
8,9
metabolism in Hashimoto’s thyroiditis patients. It is from the thyroid hormone to the hypothalamus. This leads
important to note that while MP may be associated with to excessive secretion of thyrotropin-releasing hormone
hypothyroidism, many patients with MP do not display and proliferation of TSH-secreting cells. The clinical
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the typical physical manifestations of hypothyroidism in manifestations of PHPH encompass various symptoms
the clinical context. After examining 71 case reports of MP associated with hypothyroidism such as fatigue, cold
published from 1980 to 2019, a recent study found that sensation, and myxedema, along with menstrual disorders,
only 25% of MP cases displayed non-indented peripheral galactorrhea, infertility, and other symptoms caused

Volume 2 Issue 3 (2024) 4 doi: 10.36922/jcbp.2317