Case summary

In this report, Al-Bitar and colleagues describe a 59-year-old Arab man with no psychiatric history who developed severe psychosis and convulsive episodes one month after total thyroidectomy performed for a large compressive multinodular goiter.

The patient initially underwent uncomplicated total thyroidectomy for a progressively enlarging thyroid mass causing airway compression. Histopathology confirmed benign multinodular goiter. One month postoperatively, however, he developed abrupt behavioral changes characterized by agitation, confusion, bizarre singing and clapping, aggression, destruction of property, and recurrent convulsive episodes.

A striking cyclical pattern emerged. Episodes recurred monthly and lasted hours to days, followed by prolonged sleep lasting up to 24–48 hours and complete amnesia for the events. Laboratory evaluation demonstrated profound metabolic derangements with thyroid-stimulating hormone (TSH) levels >75 mIU/L and severe hypocalcemia (6.1 mg/dL), consistent with concurrent iatrogenic hypothyroidism and hypoparathyroidism-induced hypocalcemia.

The authors diagnosed psychotic disorder secondary to another medical condition caused by dual metabolic insults. Treatment included levothyroxine, calcium carbonate, calcitriol, olanzapine, aripiprazole, and sertraline. Clinical improvement was rapid, with complete resolution of psychosis, convulsions, aggression, and cyclical episodes within two months.

The discussion emphasizes the synergistic neuropsychiatric effects of hypothyroidism-induced cerebral metabolic depression and hypocalcemia-induced neuronal hyperexcitability. The authors further propose that the cyclical episodes with postictal somnolence may represent an epileptiform process masquerading as primary psychosis.

Why this case matters

• Highlights a rare but severe neuropsychiatric complication after thyroidectomy
• Demonstrates synergistic CNS dysfunction from concurrent hypothyroidism and hypocalcemia
• Reinforces that metabolic disturbances can mimic primary psychiatric disease
• Suggests possible epileptiform mechanisms underlying cyclical psychosis with postictal features
• Emphasizes the importance of postoperative endocrine monitoring after thyroid surgery

Clinical Take-Home Message

Acute psychosis, agitation, or convulsive episodes following thyroidectomy should immediately prompt evaluation for severe hypothyroidism and hypocalcemia, as rapid metabolic correction can lead to complete neurological and psychiatric recovery.

Question:

What metabolic combination most likely precipitated this patient’s neuropsychiatric syndrome?

A. Hyperthyroidism and hypercalcemia
B. Hypothyroidism and hypocalcemia
C. Hypernatremia and hyperglycemia
D. Hypomagnesemia and hyperparathyroidism

Correct answer: B. Hypothyroidism and hypocalcemia

Explanation:
The patient developed concurrent severe hypothyroidism and postoperative hypocalcemia secondary to hypoparathyroidism after total thyroidectomy. The authors propose that the combination of cerebral metabolic depression and neuronal hyperexcitability produced the severe psychotic and convulsive presentation.

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