Auditory hallucinations in a 15-year-old boy: an unusual presentation of hypothyroidism

Abstract

It is well recognised that thyroid disorders may present with a wide range of symptoms and signs in adults and children. We describe an unusual presentation of thyroid disease in an adolescent with psychiatric symptoms, in whom normalisation of his thyroid function resulted in significant improvement in his mental state. Although agitation and depression are commonly listed as symptoms of hyper- and hypothyroidism, respectively, presentation to psychiatric services is not well documented in the adolescent age group and thyroid function tests are not a routine inclusion as part of a paediatric psychiatric assessment.

BACKGROUND

While hypothyroidism is classically associated with mental slowing and low mood, this case is of interest in its presentation with disturbing auditory hallucinations. This positive symptom gradually decreased in frequency and severity correlating with normalisation of the patient’s thyroid function tests (TFTs).

CASE PRESENTATION

A 15-year-old Bulgarian boy presented to the accident and emergency (A&E) department in September 2008. Previously fit and well, he described a 2 week history of “hearing a computer in his head”, which he believed someone else had put there. He also described the feeling that someone else next door was saying what he was thinking. His parents had become increasingly concerned due to his progressive agitation and that he now was unable to sleep with the perceived voices continuing throughout the night. He denied any visual hallucinations, although his vision was subjectively darker than previously. There was no evidence of paranoid thoughts or routine behaviours, and he also denied drug or alcohol use.

On examination he was noted to be of short stature, height was below 0.4th centile, and weight above the 25th centile. He had a lack of pubescent facial hair development and a resting heart rate of 62 beats/min. Subsequent paediatric review revealed bilateral hydroceles, a central distribution of body fat with gynaecomastia, reduced pubic hair, and a smooth symmetrical goitre.

INVESTIGATIONS

He had a marginally raised alanine aminotransferase (ALT) of 57 u/l (normal range (NR) 0–37 u/l) and creatinine of 126 μmol/l (NR 59–89 μmol/l). His TFTs revealed thyroid stimulating hormone (TSH) >150 miu/l (normal range (NR) 0.25–5.0 miu/l) and free T4 of 4 pmol/l (NR 9–23 pmol/l). A thyroid autoantibody screen was positive with anti-TPO antibodies >1000 IU/ml. His calculated bone age was 12 years 6 months. An ultrasound of his scrotum confirmed bilateral hydroceles and normal testes. Following thyroid replacement treatment, TSH lowered dramatically to 0.4 miu/l, with a free T4 of 14 pmol/l. Repeat liver and renal function tests were normal.

DIFFERENTIAL DIAGNOSIS

Although his short stature did alert the A&E medical staff assessing this boy to a potential organic cause for his symptoms and serological investigations were requested, an urgent review by the psychiatric team concluded that this could be an acute psychotic episode. There was no family history of psychiatric disease, although he had notably moved to the country only a year previous to this encounter and spoke poor English, leaving him isolated and bullied at school.

TREATMENT

He was initially started on a low dose of quetiapine (150 mg twice daily) for a presumed psychotic episode. However, this was discontinued on receipt of his thyroid function assays and review by the paediatric team. Thyroxine was initially commenced at 50 μg per day and titrated up to 100 μg until thyroid function had normalised.

OUTCOME AND FOLLOW-UP

Over a period of 2 weeks the episodes of audible voices gradually reduced, then stopped, although he retained memory of the events. At 1 month post-treatment the boy and his parents felt he had more energy. He was noted to look less typically myxoedematous on review, although his hydroceles and goitre remained unchanged.

DISCUSSION

It is well recognised that adults presenting with acute psychotic symptoms may have underlying or associated thyroid dysfunction, with screening TFTs being often requested in this age group.³ However, it is not documented as a likely presentation of thyroid disorder in adolescents and children, and routine thyroid tests have not previously been recommended.^1,2 However, if other suggestive symptoms or signs, such as short stature, goitre or hydroceles, are evident, one should have a low threshold for TFTs.^1,2 It is clear that this assay was extremely beneficial in our case. Since the previous recommendations were published, TFTs have become more widely available, and where they are now a routine inclusion in presentation of “soft” and subjective symptoms such a tiredness and lethargy in adults, there may be more of a case to include them as a routine part of a paediatric psychiatric screening assessment.^1–4

No clear correlation appears to exist between psychiatric presentation and degree of severity in thyroid dysfunction.^1,2 Appropriate thyroid treatment usually results in resolution of the psychiatric symptomatology.² The treatment should therefore aim to target first the underlying endocrinopathy rather then the psychiatric component.^1–3 Discontinuation of the thyroid treatment has been reported to lead to the return of the psychiatric symptoms.³

This case illustrates the need to consider thyroid dysfunction in the differential diagnosis of any adolescent presenting with acute onset of psychiatric disorders.

LEARNING POINTS

• In childhood, as well as in adults, psychiatric symptoms may have an underlying thyroid function abnormality.

• It is important to elicit any other symptoms and signs by a thorough physical assessment, including neck examination.

• A low threshold is needed for ordering thyroid function tests on any child or adolescent presenting with acute psychotic symptoms.

• With normalisation of thyroid function tests one can reasonably expect resolution of psychiatric symptoms.