Myxedema Psychosis: Neuropsychiatric Manifestations andRhabdomyolysis Unmasking Hypothyroidism

Hypothyroidism is a prevalent endocrine disorder, often presenting with a spectrum of symptoms reflecting ahypothyroid state. It is also generally linked to causing mood swings, psychomotor slowing, and fatigue; however, in rareinstances, it may lead to or induce acute psychosis, a condition referred to as myxedema psychosis (MP). We report a case ofmyxedema psychosis and present a literature review discussing its presentation, diagnosis, management, and prognosis.CasePresentation. A 36-year-old lady presented with one-week history of persecutory and paranoid delusions, along with visual andauditory hallucinations. She had no prior history of psychiatric illnesses. She underwent total thyroidectomy three years beforethe current presentation due to papillary thyroid cancer. She was not on regular follow-up, nor any specific therapy. Onexamination, she was agitated and violent. There were no signs of myxedema, and the physical exam was unremarkable. Theinitial workup showed a mild elevation in serum creatinine. Additional investigations revealed a high thyroid-stimulatinghormone (TSH) of 56.6 mIU/L, low freeT4<0:5pmol/L, elevated creatine kinase of 3601 U/L, and urine dipstick positive forblood, suggestive of myoglobinuria. MRI of the head was unremarkable. We diagnosed her as a case of myxedema psychosis andmild rhabdomyolysis. She was started on oral thyroxine 100 mcg/day,fluoxetine 20 mg daily, and as-needed haloperidol. Shewas closely followed and later transferred to the Psychiatry Hospital for further management. Within one week, her symptomsimproved completely, and she was discharged offantipsychotics with additional scheduled follow-ups to monitor TFTs andobserve for any recurrence.Discussion and Conclusion. Myxedema psychosis is a rare presentation of hypothyroidism—acommon endocrine disorder. Scarce data are describing this entity; hence, there is currently a lack of awareness amongstclinicians regarding proper identification and management. Moreover, the atypical nature of presentations occasionally adds toa diagnostic dilemma. Thus, any patient with new-onset psychosis should be screened for hypothyroidism, and awareness of thisentity must be emphasized amongst clinicians and guideline makers.