Acute mania after thyroxin supplementation in hypothyroid state
A right-handed 27-year-old unmarried Indian male nondiabetic, normotensive, vegetarian was diagnosed with hyperthyroidism 7 months earlier [antithyroid peroxidase antibody: 16.1 (reference range: 0–65) IU/mL, T3: 5.59 (reference range: 0.92–2.33) nmol/L, T4: 207.30 (reference range: 60–120) nmol/L, thyroid stimulating hormone (TSH): 0.05 (reference range: 0.35–5.5) IU/ mL, 99mTc-pertechnetate thyroid scan suggestive of thyroiditis] and started on medications (neomercozole 30 mg/day) by an endocrinologist. Three months later he started complaining of weakness and lethargy and upon investigating his TSH levels were raised significantly [TSH: 32.7 IU/mL, T4: 8.6 (reference range: 12–22) pm/L, ultrasonography thyroid—both lobes mildly hyperechoic and heterogenous in pattern with no definite nodule or calcification seen] and he was shifted to thyroxine 25 μg per day in view of hypothyroidism. Subsequently, after about a week of treatment, he developed manic symptoms (euphoria, increased talkativeness, over familiarity, over religiosity, increased energy levels, reduced need for sleep, abusive and violent behavior with socio-occupational dysfunction). He presented to psychiatry department with 2 months history of such symptoms and was admitted. Upon investigating, TSH levels were found to be within normal limits with increased T3 [T3: 5.48 (reference range: 2–4) pg/dL, T4: 1.30 (reference range: 0.6–2) ng/dL, TSH: 3.74 IU/ mL]. His manic symptoms remitted within 5 days of stopping thyroxine and initiating valproate 800 mg/ day and olanzapine 20 mg/day. His Young Mania Rating Scale[] scores (to assess improvement in mood symptoms) reduced from 28 to 11 in 5 days and thyroid hormone levels normalized within 20 days.\nPatient was euthymic with normal thyroid hormone levels after 2 months of followup wherein his medications were tapered off and did not show mood symptoms when seen 2 months later.