She developed slowly during childhood and was shorter compared to her peers of the same age. She had significant academic difficulties, did not finish primary education, and never had a job. She did not experience the onset of menstruation after puberty. She married when she was 32 years old, but never had children.
Because of amenorrhea and short stature, she gradually became depressed and self-blamed, had no self-confidence, and believed she was useless. She isolated herself at home and hesitated to meet others. She had poor appetite and sleep and tried to suicide. Because of these problems and symptoms, she was admitted to the mental health center in 1991. She was diagnosed with depression and secondary hypopituitarism and treated with doxepin, which did significantly improve her symptoms.
In November 1992, the patient was admitted to the center again for depressive mood and suspicion of others. She suspected that her home had been stolen by one of her sisters-in-law and showed lack of impulse control and loss of temper. She was diagnosed with depression and depression-induced psychotic disorder. After perphenazine (16 mg/day) and doxepin (100 mg/day) treatments, her symptoms improved, and she was discharged from the center. At home, she kept up with taking her medication.
In 1995, after the discontinuation of the medication, she was admitted to the center a third time for excessive talking, hyperactivity, buying things for others without reason, and excessive praying. At home, she had difficulty controlling herself and would have outbursts with shouting and crying and other disruptive behavior. She was diagnosed with affective disorder with manic episodes, pulmonary tuberculosis, which was shown in a chest X-ray, and hypopituitarism. Her symptoms improved after treatment with antituberculosis drugs and clozapine, after which, she was discharged from the center.
The patient was hospitalized in both 2001 and 2004, for the same manic episodes including excessive talking, hyperactivity, rash spending, and difficulty controlling herself.
In 2005, the patient became depressed and stupefied, slow in her movements, lazy, and maintained erratic hours. During hospitalization, a karyotypic analysis was performed and the karyotype of 45, X/46, X, i(Xq) was identified which led to the diagnosis of TS. An endocrinologist initiated estrogen and progestin replacement therapy, and sodium valproate (1.0 g/day) was also prescribed. The patient's mood stabilized, and she was discharged from the center; however, she did not continue the estrogen and progestin replacement therapy. Menses was present during the second cycle of treatment.
In 2009, the patient was hospitalized again for a manic episode. During hospitalization, her fasting blood sugar was found to be high, leading to a diagnosis of diabetes mellitus for which metformin was prescribed, in addition to sodium valproate for the manic symptoms.
It was concluded that the previous diagnosis of hypopituitarism was incorrect as there was no laboratory evidence to support this diagnosis. Unfortunately, the misdiagnosis had not been corrected until 2005 when a karyotype of 45, X/46, X, i(Xq) was identified. It is likely that the psychiatric practitioner was not knowledgeable regarding TS and hypopituitarism.