Endocrine Abstracts

A previously fit and well 27 year old Ghanaian male was brought to hospital by his cousin due to new behavioural changes. The patient was described by his cousin as a normally reserved, self-sufficient man who had become a polar opposite ‘irritable’ personality that ‘spent extravagantly’. He repeatedly claimed to be ‘God’s protection’ and responded aggressively to visual hallucinations. This had resulted in social exclusion and loss of employment. There was no significant family history or history of substance or alcohol misuse. Physical assessment was limited due to poor patient co-operation. Bedside observations revealed a marked resting tachycardia (121 bpm). Oxygen saturations, blood pressure and temperature were all normal. There was no apparent focal neurological deficit or neck rigidity. The remaining physical examination was positive only for a non-tender goitre and hand tremors. Electrocardiography confirmed sinus tachycardia. Computerised tomography (CT) head scan was normal and lumbar puncture was unsuccessful despite sedation. Initial investigations revealed a mild inflammatory response without electrolyte disturbances. He was treated empirically for meningoencephalitis, however, further urgent investigations confirmed marked hyperthyroidism with free T4 95 pmol/l (10–19.9 pmol/l) and TSH <0.01 mU/l (0.35–5.5 mU/l). A diagnosis of thyrotoxic psychosis was made. He was commenced on high-dose carbimazole and propranolol 160mg daily in divided doses with little effect. Hydrocortisone, lithium and cholestyramine were subsequently added to help achieve euthyroidism with a consequential improvement in his mental state. A total thyroidectomy was performed to achieve definitive control. He was successfully discharged a few days later on levothyroxine and was given a supporting medical letter to help to cancel the multiple phone contracts and loans that he had accumulated during his thyrotoxic state. Histological evaluation of the excised thyroid gland confirmed Graves’ thyrotoxicosis.

Conclusion: Thyrotoxic psychosis, although rare, should be considered in all patients with behavioural disturbances to allow early treatment, prompt control and improved outcomes.