To describe the presence of psychotic symptomatology in a patient with hyperthyroidism

Psychiatric-spectrum symptoms associated with thyrotoxicosis has been well reported in the past. However, psychosis in a patient with a thyroid nodule is a rare find. Here, the case of twenty four-year-old, single, unemployed, Albanian American male with self-reported history of Attention Deficit Disorder (ADD) and Cannabis use disorder was brought in to the Comprehensive Psychiatric Emergency Program (CPEP) due to new onset psychosis. Patient was paranoid, disorganized with labile mood. He had poor insight, judgement and impulse control. The event coincided with a period of unemployment in his life and new onset of hallucinations from past few days. He was brought in to the hospital after he was found pacing and having lack of sleep. Patient was treated with antipsychotic for acute psychosis. He was started on Risperidone initially to which he did not respond to. Blood work showed low TSH and elevated T4. Physical exam was noted for palpable thyroid nodule. Further labs resulted in high thyroid peroxidase antibody. Ultrasound of thyroid with color flow showed single nodule in the left lobe and iodine uptake activity localized to the left lobe. Patient was started on Methimazole 5 mg along with Haldol 5mg orally twice a day which improved his symptoms tremendously. Patient was stabilized and after 1 week was discharged on Haldol 5 mg by mouth two times a day for Psychosis, Cogentin 1 mg by mouth two times a day for extrapyramidal system (EPS), and Methimazole 5 mg by mouth daily for overactive thyroid nodule.

Psychosis associated with thyroid nodule is rare but possible. The onset of psychotic syndrome is an important clinical element whose underlying medical cause must be promptly clarified. Psychosis can present in a number of ways and can have different causes. Apart from psychiatric causes, underlying medical causes should always be considered. In this case it was important to get a full clinical history of the patient as well as complete physical examination. The differential diagnosis of a psychotic disorder in light of a medical disease should always be considered in order to promptly diagnose and treat the underlying cause to reduce the morbidity and possibly the mortality associated with it.