A 58-year-old female with a history of lupus and plaque psoriasis presented to the emergency department with new onset hallucinations and suicidal ideation, as well as one witnessed attempt to throw herself into traffic. The patient was brought to the hospital after what her husband said were three days of the patient talking to people who were not there, crying frequently, not sleeping, openly expressing a desire to die, and one attempt to run from their home to a nearby highway in order to jump in front of a car. The patient's husband had chased after and restrained her, after which he brought her to the hospital.
The husband relayed that the patient had never before in the course of their 35-year marriage behaved in this manner, and he further insisted that the patient was previously generally "happy and smiling." In-house hospital records showed a long history of lupus and psoriasis management as well as a recent admission two weeks prior for mastoiditis; she had received IV clindamycin and ceftriaxone and then been discharged on oral clindamycin. There was no record of any mental health history.
The medical records showed that, during the recent hospital admission, the patient was discovered to have a depressed thyroid stimulating hormone (TSH) level; she was diagnosed with hyperthyroidism and treated with methimazole (MMU) and propranolol for presumed Grave's disease. At the time of discharge, she was continued on a half dose of methimazole. Propranolol was discontinued before discharge based on clinical response to treatment, with endocrinology clinic follow-up scheduled for three weeks from the time of discharge.
The patient's husband further relayed that the patient had been searching their home for a knife for the past two days while telling him that she "needed to die," compelling him to remove all kitchen knives from their home. On interview, the patient was asked why she was looking for a knife and she responded "because I want to die."
The patient and her husband both denied any recent head trauma. They both further denied any alcohol use or illicit drug use. The patient denied any abdominal pain, diarrhea, dysuria, vomiting, or shortness of breath. She endorsed restlessness, palpitations, and a sensation of "feeling too hot."
On exam, blood pressure was 145/88, temperature was 37.5, respirations were 17, oxygen saturation was 99 percent on room air, and heart rate was 129 beats per minute. On the cardiac monitor, she was in gross atrial fibrillation, which had previously not been documented in her medical record. During the exam, the patient was noted to have rapid, pressured speech. Voice volume was normal, and her mood was depressed. She became tearful during the interview, and she intermittently appeared to be responding to internal stimuli. Of note, she seemed to be quite open about all her symptoms and was an excellent historian. She freely admitted to suicidal ideation (SI) and audiovisual hallucinations (AVH). She admitted to attempting to run into traffic in order to kill herself. She described hearing what she described as supernatural voices speaking to her; she said that she could see "spirits and lions" that were likewise speaking to her. She did not believe that the voices were telling her to kill herself but rather said that she wanted to die "because I am so sad." She was oriented to her name only. She did not know the year and believed she was currently in a prison. She asked the doctor for a knife several times. She also said that she felt as though she wanted to start running "because I can't keep my legs from moving." She had pulled all the blankets off the bed, had removed much of her hospital gown, and asked if she could have some ice water "because it is so hot in here," despite the fact that the emergency department was air-conditioned. The remainder of the exam was notable for an irregularly irregular heartbeat, clear lungs, tongue fasciculations, tremulousness, diffuse hyperreflexia, and a large, nontender thyroid gland.
The patient was placed on a medical detainment and assigned a one-to-one sitter to monitor her. Psychiatry was consulted. An electrocardiogram was ordered, which showed sinus tachycardia with resolution of the previously noted atrial fibrillation. Urine toxicology was negative. Labs showed a slightly low potassium level, in keeping with a hyperadrenergic state. TSH was undetectable.
It was well past midnight, so the decision was made to treat empirically for thyroid storm. Propranolol 80 milligrams PO and methimazole (MMU) 20 milligrams PO were ordered. The patient took the medication without any resistance. She was given a large cup of ice water, as well as an IV bolus of a liter of normal saline. Endocrinology was consulted, and the head of endocrinology began driving to the hospital from his home to see the patient. Dexamethasone 10 milligrams IV was then given. Meanwhile, the psychiatry service interviewed the patient. They agreed with the plan to treat for hyperthyroidism and placed the patient on a 72-hour psychiatric hold for danger to self and grave disability.
Two hours after treatment was initiated, the patient's heart rate had slowed to 89 beats per minute. The cardiac monitor showed normal sinus rhythm. Tongue fasciculations had stopped, though hyperreflexia remained. The patient said that she felt "so much better" and was at this point denying SI and AVH. She showed insight into her condition, saying "I was feeling very upset and scared. I was seeing lions, and they were talking to me. I was so scared. I could hear voices that I knew weren't there, but I felt so sad about how I felt that I wanted to die." She wanted to know what medicine she had been given that had made her feel better, and she asked if she could have a prescription for it.
Endocrinology consult arrived and assessed the patient, likewise finding hyperreflexia and an enlarged thyroid gland. Endocrinology made a diagnosis of thyroid storm in the setting of Grave's disease. Both consult services recommended a brain MRI to rule out an intracranial process. This showed no evidence of bleeding or stroke, nor any evidence of lupus cerebritis (which had been included on the differential due to the patient's lupus history).
The patient was admitted to medicine and was followed by psychiatry. The day after admission, she again began endorsing SI and AVH. Free T4 and T3 levels at this time were 2.10 ng/dL and 2.09 ng/dL, respectively. Psychiatry recommended olanzapine (Zyprexa) 5 milligrams daily, which was initiated to good effect. Propranolol, MMU, and steroids were continued and adjusted based on endocrine consult recommendations. Thyroid stimulating immunoglobulin (TSI), ordered as a send-out lab during the patient's previous admission for mastoiditis, returned positive, and the diagnosis of Grave's disease was made.
As the patient's thyroid labs normalized, her psychiatric symptoms resolved. Olanzapine was discontinued at the recommendation of psychiatry. Endocrinology recommended radioactive iodine ablation of her thyroid gland, which was scheduled and then aborted when she was found to have sudden onset pancytopenia, a well-documented side effect of methimazole. Methimazole was discontinued, and her cell lines began to recover. After thorough reassessment, psychiatry lifted the hold, and the patient was discharged from the hospital on a steroid taper and propranolol.