General Hospital Psychiatry 35 (2013) 683.e1–683.

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General Hospital Psychiatry

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Case Report

Acute mania in a patient with hypothyroidism resulting from Hashimoto's

Thyroiditis☆,☆☆,★
Chia-Lin Lin, M.D. a, Szu-Nian Yang, M.D., M.S. a, I-Shin Shiah, M.D., Ph.D. b,⁎
a
Department of Psychiatry, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
b
Dr. Shiah's Psychiatric Clinic, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Hashimoto's thyroiditis (HT) is an autoimmune thyroiditis that occurs frequently in middle-aged women. To
Received 22 April 2013 date, there is no formally reported association between acute mania and hypothyroidism due to HT. We report a
Revised 24 June 2013 case of acute mania associated with hypothyroidism resulting from HT. Our patient's mania and hypothyroidism
Accepted 25 June 2013
remitted gradually after the treatment with mood stabilizer/antipsychotic drugs and levothyroxine therapy. This
case highlights the importance of ascertaining thyroid function and checking antithyroid antibodies in middle-
Keywords:
Acute mania
aged female patients with affective symptoms to the hospital for the first time.
Hashimoto's thyroiditis © 2013 Elsevier Inc. All rights reserved.
Primary hypothyroidism
Psychosis

1. Introduction
Only 13 cases of acute mania associated with primary hypothy-
roidism have been reported in the literatures [1–4]. Two of these cases
involved increased antithyroid antibodies [2,3]. None of the 13 cases
was formally diagnosed as Hashimoto's thyroiditis (HT) [1–3],
although this autoimmune thyroiditis is the likely cause of the
reported cases of hypothyroidism. We present a case of acute mania in
a 41-year-old woman with hypothyroidism resulting from HT. The
clinical diagnosis of HT was confirmed by laboratory data. She
received both mood stabilizer/antipsychotic medications and
levothyroxine therapy. Her psychotic mania and hypothyroidism
gradually remitted within 3 weeks.
2. Case report
A 41-year-old woman had no past, personal, or family history of
medical or psychiatric illness and denied abusing any psychoactive
drug or alcohol. She was brought to the emergency room with
symptoms of elevated and expansive mood, pressured speech,
hyperactivity, decreased need for sleep, multiple plans and grandiose
delusions and visual and auditory hallucinations for 1 week.
According to the patient and her family, she had suffered from
symptoms of hypothyroidism, such as tiredness, dry skin, cold
☆ No financial support was received for this study. This article has not been
submitted either completely or in part to another journal.
☆☆ Each author participated sufficiently in the work to take public responsibility for
the content.
★ All authors declare no conflicts of interest.
⁎ Corresponding author. Tel.: +011 886 2 87929323; fax: +011 886 2 87929325.
E-mail address: ishiah@ms45.hinet.net (I.-S. Shiah).
intolerance, weight gain (63 to 69 kg) and abnormal menstrual cycle
in the past 3 months. However, she did not have symptoms of
constipation, thinned eyebrows, slow body movement, hoarseness,
muscle aches or facial puffiness. On examination, she was conscious,
and her orientation was intact. In addition to her psychotic mania, the
patient showed myxedema, a physical sign suggestive of hypothyroid-
ism. She did not show any palpable nodules or enlarged thyroid glands.
Her neurological and other physical examinations were unremarkable.
Her laboratory examinations, including blood and urine tests,
glucose, electrolytes, renal and liver function, chest radiograph and
electrocardiography, were all normal. However, her free levothyroxine
(fT4) level was low at 0.24 ng/dl (0.70–1.48 ng/dl), and thyroid
stimulating hormone (TSH) was elevated at 18.79 mIU/L (0.35–
4.94 mIU/L). Furthermore, her antithyroglobulin antibodies were
445 IU/ml (0–60 IU/ml) and antithyroid peroxidase antibodies were
411 IU/ml (0–60 IU/ml). After the patient and her family gave informed
consent, the ultrasonography of the thyroid glands was performed
and showed a diffusely heterogeneous and hypoechoic pattern but no
nodular lesions. Fine-needle aspiration cytology (FNAC) was performed
and showed that follicular cells were infiltrated by lymphoid cells but
no evidence of malignancy.
Given the diagnosis of HT with a hypothyroid phase, the patient
was given levothyroxine. The initial dose of levothyroxine was
90 mcg/day (i.e., 1.6 mcg/kg). However, she developed intolerable
side effects, including nausea, headaches, palpitation and sweating.
Thus, we decreased her dose of levothyroxine to 25 mcg/day. Five
days later, the dose of levothyroxine was increased to 50 mcg/day.
Simultaneously, the patient was started on valproate (800 mg/day)
and quetiapine (400 mg/day) on the first admission day to treat
her psychotic mania. Her symptoms of hypothyroidism and
psychotic mania remitted within 3 weeks. Her psychotropic

0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
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medications were discontinued 4 weeks later, and she was
discharged in stable condition.
After being discharged, the patient was well on levothyroxine for 2
years and took no psychotropic medication. Levothyroxine was
increased to 75 mcg/day for the first 6 months. With levothyroxine
maintenance therapy, the patient's abnormal thyroid function gradually
returned to normal levels (fT4: 1.01 ng/dl; TSH: 4.21 mIU/L).
Levothyroxine was reduced to 50 mcg/day for the following 6 months.
After the 6-month therapy, the patient remained euthyorid (fT4:
1.18 ng/dl; TSH: 3.91 mIU/L). We therefore decreased levothyroxine to
25 mcg/day for another 12 months. Follow-up thyroid function tests at
the last visit (fT4: 0.97 ng/dl; TSH: 3.79 mIU/L) were still within normal
limits. Thus, we discontinued levothyroxine after the 2-year follow-up.
She did not show any recurrent mania, psychosis or depression.
3. Discussion
HT, an autoimmune thyroiditis, is characterized by chronic
lymphocyte infiltration of thyroid glands. The disease is six to eight
times more prevalent in women than in men. It is most likely to occur
between the ages of 30 and 50 [5].
Diagnosis of HT can be made based on clinical manifestations of
hypothyroidism along with high TSH level and antithyroid antibody
tests [1,5]. Most patients with HT present with diffuse thyroid
enlargement; only approximately 10% present without thyroid
enlargement, known as the atrophic form [5]. FNAC is necessary in
these uncertain cases [5]. Our reported case did not have enlarged or
palpable thyroid glands. Her diagnosis of hypothyroidism due to HT
was confirmed by thyroid function tests, antithyroid antibodies and
the FNAC pathological results.
It is important to determine whether our case of psychotic mania
was a primary psychiatric disorder or secondary to the patient's
hypothyroidism. Notably, she had no past, personal or family history
of psychiatric disorders or of alcohol or psychoactive drug abuse. Her
psychotic mania remitted after treatment with mood stabilizer/
antipsychotic medications and levothyroxine for 4 weeks. She showed
no recurrence of mania, depression or psychosis at her 2-year follow-
up. In view of the atypical age of the onset of mania and the presence
of visual hallucinations during her manic episode, physicians or
consulting psychiatrists in general hospitals should consider this
psychotic mania secondary to HT-induced hypothyroidism.
Being female and middle-aged are risk factors for developing
hypothyroidism [1,5]. Thus, we concur with Khemka et al.'s proposal
[1] that thyroid function should be routinely checked in middle-aged
female patients with mania or depression to exclude the possibility of
hypothyroidism. We suggest that screening of antithyroid antibodies
for any patient with affective symptoms and thyroid dysfunction is
needed because prompt recognition and management of HT can lead
to excellent treatment outcomes.
References
[1] Khemka D, Ali JA, Koch CA. Primary hypothyroidism associated with acute mania:
case series and literature review. Exp Clin Endocinol Diabetes 2011;119:513–7.
[2] Stowell CP, Barnhill JW. Acute mania in the setting of severe hypothyroidism.
Psychosomatics 2005;46:259–61.
[3] Torr TC, Lee HY, Fones CS. Late-onset mania with psychosis associated with
hypothyroidisim in an elderly Chinese lady. Singapore Med J 2007;48:354–7.
[4] Chakrabarti S. Thyroid functions and bipolar affective disorder. J Thyroid Res 2011:
1–13.
[5] Amino N, Hidaka Y. Chronic (Hashimoto’s) thyroiditis. In: DeGroot LJ, Jameson JL,
editors. Endocrinology. 5th ed. Philadelphia: Elsevier Saunders; 2006. p. 2055–68.