Psychosis with untreated hypothyroidism: How a generalist made a difference

TL;DR

A man misdiagnosed with schizophrenia was found to have psychosis caused by severe hypothyroidism, highlighting the importance of thorough evaluation in primary care.

Contribution

This case emphasizes the role of primary care providers in identifying rare organic causes of psychosis.

Findings

A patient with psychosis was found to have myxoedema psychosis due to severe hypothyroidism.

Treatment with levothyroxine led to significant clinical improvement.

The case highlights the consequences of misdiagnosis in atypical psychiatric presentations.

Abstract

Myxoedema psychosis is a rare but treatable condition resulting from severe hypothyroidism. We report the case of a man who presented to a primary healthcare facility seeking a medical report for financial assistance, having lost his job after being treated for schizophrenia. A comprehensive re-evaluation raised the possibility of endocrinopathy-induced psychosis as one of the differentials. The diagnostic process was challenging due to the rarity of the condition and the absence of classic hypothyroid features. Laboratory investigations revealed markedly low free thyroxine levels and elevated thyroid-stimulating hormone and anti-thyroid peroxidase antibody levels, confirming the diagnosis. Treatment with levothyroxine led to significant clinical improvement. This case underscores the vital role of primary care providers in recognising organic causes of psychosis through patient-centred assessment, application of primary care principles and interdisciplinary collaboration. It also highlights the potential consequences of misdiagnosis in atypical psychiatric presentations, including functional decline and job loss, and reinforces that appropriate management can lead to optimal outcomes.