Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

Thyrotoxicosis as a mimic of dementia and/or
stroke-like syndrome
Valery A. Portnoi
To cite this article: Valery A. Portnoi (1979) Thyrotoxicosis as a mimic of dementia and/or strokelike syndrome, Postgraduate Medicine, 66:4, 219-221, DOI: 10.1080/00325481.1979.11715283
To link to this article: http://dx.doi.org/10.1080/00325481.1979.11715283

Published online: 07 Jul 2016.

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CASE

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REPORT

111yrotoxicosis •
a mimic of dementia
and/or stroke-like
syndrome

POSTGRAD u ATE MEDICINE invites submission of brief case reports, especially those related to ambulatory medical care.
Illustrations and references should be included only when essential.

Valery A. Portnoi, MD

tion were observed, but no relation- . bilaterally; however, ail other primiship between them and the syncopai tive reflexes were negative.
attacks was found. Skull x-ray films
An evaluation of the patient's
An 82-year-old woman with a long were normal, but an EEG showed a mental status showed that she had
history of diabetes was admitted on burst of alpha wave activity in the only a vague recollection of the preMay Il, 1976, to the Jewish Insti- frontal area. Weight Joss of approxi- vious hospital admissions and
tute for Geriatrie Care at Long Is- mately 25 lb over the past year was thought Eisenhower was still presiland Jewish-Hillside Medical Cen- noted. No further tests were done. dent of the United States. She could
ter, New York. She had been living Despite Jack of positive neurologie not remember the major events and
in a senior citizens' hotel and re- findings, the diagnosis made was persons in her life or the names of
quired rehabilitation and manage- "status post-cerebrovascular acci- three objects for five minutes. She
ment in view of progressive episodes dent and organic brain syndrome." was unable to answer questions
of confusion, agitation, and depend- The patient was returned to the se- about place of birth and number of
ence in performing activities of daily nior citizens' hotèl.
children, interpret several proverbs,
living.
When admitted to the Jewish ln- or count backward from ten to one.
According to the patient, six stitute, the patient was alert and unSeveral days later a sudden synyears earlier a thyroid nodule that derstood verbal instructions, al- copai attack and deep lethargy dehad been found on routine physical though she demonstrated moderate veloped simultaneously with atrial
examination was determined to be difficulty with speech (slurred, fibrillation (rate 150).
"cold." For unknown reasons no without aphasie or paraphasie erDespite administration of digoxin
follow-up had been done. ln Novem- rors) and disorientation to time and (serum digoxin levet was found to be
ber 1975 she was admitted to an- place. She was emaciated, with 2 ngjml), rapid atrial fibrillation
other hospital and diabetes mellitus prominent muscle wasting; skin was continued. Thyroid studies showed
was diagnosed. Two weeks later she moist and warm; temperature was thyroxine (T 4) levet of 18.4 Mg/dl
was discharged on a regimen of 20 normal; and no bruits were heard on (normal up to 15) and triiodothyronine (T3 ) resin uptake 45%
units of isophane (NPH) insulin auscultation.
A palpable thyroid nodule 2 to 3 (normal 35%).
daily.
Sinus rhythm returned spontaneOn March 12, 1976, she was cin in diameter on the right lobe was
readmitted to the same hospital with · firm but not tender. There was no ously, and after two days of mental
obtundation and aphasia, the pasyncopai attacks following episodes lymphadenopathy or exophthalmos.
The only focal neurologie signs tient was severely confused, restless,
of confusion and slurred speech. At
that time there was no evidence of were brisk tendon reflexes and and agitated, with combativeness
an insulin reaction or signs of dia- slight tremor of the extremities. and incoherent speech. She was inbetic, nonketotic coma. Several epi- There were no tongue tremors. The continent of feces and urine and unsodes of paroxysmal atrial fibrilla- palmar-mental reflex was present able to feed herself or to perform
continued

VOL 66/NO 4/0CTOBER 1979/POSTGRADUATE MEDICINE

219

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simple daily activities. She remained
awake throughout the night.
A psychiatrie consultant suggested that the patient bad sustained severe brain damage from either brain metastasis or severa!
brain infarctions. Results of a brain
scan were not reliable, as the patient
presented great management problems during the test, despite being
highly tranquilized. Thyroid scan
revealed a multinodular goiter with
variable function. One palpable
node was quite "cool."
On completion of diagnostic studies, the patient was given propylthiouracil, 100 mg every eight hours,
but agitation, combativeness, and
incontinence continued, alternating
with periods of deep lethargy. After
severa! weeks of antithyroid therapy, she began responding to treatment. She was alert, continent, and
oriented to person, place, and time.
She slept weil and was no longer agitated. Her speech was fluent and
clear. She began socializing with
other patients and visitors and graduated to a level of independence in
ambulation and in performing daily
activities.

Val«y A. Portnoi
Dr Portnoi was formerly a fellow in geriatrie
medicine, Jewish Institute for Geriatrie Care
at the Long Island Jewish-Hillside Medical
Center, New York. He is now director,
geriatrie medicine division, George Washington University Medical Center, Washington,

oc.

220

recognized that unusual neurologie
and psychotic manifestations, which
he named the encephalopathetic
form, can predominate in the picture of hyperthyroidism without
storm as weiL He pointed out that
insomnia is an indicator of development of full-blown neuropsychiatrie
manifestations.
In 1956 Charman and Maloofl
described severa! bizarre manifestations of hyperthyroidism. Two elderly women bad encephalopathy.
One patient who responded only
"yes" to questions had aphasia asso-ciated with restlessness and whining. The second patient was disoriented, delirious, and unable to comDiscussion
An apathetic form of thyrotoxicosis, municate. 8oth responded favorably
with lethargy and depression, is not to antithyroid treatment.
Ronnov-Jessen and Kirkegaard4
uncommon in the elderly. However,
as this case demonstrates, an acti- reported in 197 3 in a survey of elvated form, with agitation, confu- derly thyrotoxic patients that athsion, restlessness, hyperkinesis, and erosclerotic cerebrovascular disease
slurred speech, can occur in the el- bad been tentatively diagnosed in
derly. This type of hyperthyroidism in three cases before the correct diagaged patients can be easily inter- nosis of thyrotoxicosis was made.
preted as a psychotic form of orIn addition, Wells5 reported one
ganic brain syndrome.
patient with thyrotoxicosis among
In 1939 Cookson and Birm 1 men- 222 patients with dementia.
tioned nine cases of psychosis in elThyrotoxicosis can be the. cause of
derly patients with thyrotoxicosis, but psychoses severe enough to require
details were not given. Walden- hospitalization. A survey of a large,
strom2 in 1945 published histories of public mental hospital showed an inten cases of hyperthyroidism with cidence of about one case of thyropsychosis and neurologie findings, toxicosis per 1,000 admissions. Howsuch as hemiparesis or bulbar paral- ever, in aU three cases discovered
ysis. Although signs of thyroid in this study, antithyroid treatment
storm were present in each case, he was dramatically effective.6
•
On mental evaluation, the patient
demonstrated good memory~ For example, she could remember the
names of three objects for five minutes, ber place of birth, the present
president of the United States, the
names and ages of ber children, and
the activity of the past day.
Since the patient and ber family
refused surgical or radioactive therapy, the patient was transferred to a
health-related facility where propylthiouracil treatment was continued.
On follow-up one year later, her cardiovascular, mental, and general
condition remained stable.

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Conclusion
The case reported here and others
like it indicate that thyrotoxicosis
can be manifested by psychosis or bizarre neurologie signs. Thus, hyperthyroidism in late life may be overlooked and the patient given the diagnosis of psychosis secondary to
organic brain syndrome or cerebrovascular accident. Thyrotoxicosis,
which is treatable, should be looked
for as a possible cause of deterioration of mental function with or without focal neurologie signs.
Address reprint requests to Valery A. Portnoi, MD. Geriatrie Medicine Division,
George Washington University Medical
Center, Washington, DC 20037.

References

1. Cookson H, Birm B: Taxie goiter. Lancet
2:1363-1368, 1939
2. Waldenstrom J: Acute thyrotoxic cncephalo- or myopathy: lts course and treatment.
Acta Med Scand 121:251-294, 1945
3. Charman EM, Maloof F: Bizarre clinical
manifestations of hyperthyroidism. N Engl J
Med 254:1-5, 1956
4. Ronnov-Jessen V, Kirkegaard C: Hyperthyroidism: A disease of old age? Br Med J
1:41-43, 197 3
5. Wells CE (Editor): Dementia. Ed 2. Philadelphia, FA Davis Co, 1977. p 250, table 1
6. Bluestone H: Hyperthyroidism masquerading as a functional psychosis. Am Pract
8:557-558, 1957