ESPE Abstracts

Background: Prominent psychiatric symptoms in hyperthyroidism in children are extremely rare, with the exception of thyroid crisis. Here we report a case with a history of delusional symptoms and impulsive behavior over several years, diagnosed and treated as Graves' disease.

Case report: A 14-year-old female patient was admitted to our hospital with cytomegalovirus infection. While in hospital, her mother declared a history of psychiatric hospitalization and a noted goiter, which necessitated thyroid screening. Her past history in infancy was unremarkable except that her mother divorced and remarried when she was 1 and 5 years old, respectively. She was diagnosed with hyperactivity at the age of 6, and goiter around the age of 9. Iodine restriction was indicated rather than medication, without thyroid function test, as her grandmother had Graves’ disease. From 10 years old, she began to show impulsive behavior such as suicide, overdose of over-the-counter drugs, and alcoholic consumption. She was referred to psychiatrist with mood instability and diagnosed with depression at the age of 12. Despite treatment with antidepressant medications, she had several episodes of coma, false reporting based on paranoia, and suicidal behavior. One year prior to the admission to our hospital, she was admitted to another hospital with coma and agitation. Laboratory test reported undetectable TSH (<0.05 mIU/L), FT4 of 4.01 ng/dL, and TSAb of 208 % (reference: <120). Despite the suspicion of Graves’ disease, she was transferred to a psychiatric ward, because of her severe hallucination, and violent behavior. After the transfer, without any antithyroid therapy, her FT4 returned to normal, while TSH remained undetectable. As her hallucination alleviated, she was discharged on anti-anxiety drugs only, but then she self-interrupted her hospital visits and continued to engage in impulsive risk-taking and delusional lying. Back to the story at our hospital, she was afebrile, had mild tachycardia with 88 beats/min, and a blood pressure of 106/53 mmHg. She had mild goiter without exophthalmos. At the initial interview, she was conscious, but she showed irritability, reduced eye contact, and disengaged facial expression. Laboratory test reported undetectable TSH, FT4 of 3.89 ng/dL, TRAb of 5.1 IU/L (reference: < 2.0), and TSAb of 267 %, consistent with Graves’ disease. She responded well to thiamazole treatment and achieved euthyroidism as well as improved mental stability.

Conclusion: This case highlights the benefit of antithyroid treatment in children with hyperthyroidism and psychiatric symptoms, whether overt or subclinical.