CASE REPORT

Ms. A, a 73-year-old woman without known significant past medical history, presented with a 2-week history of auditory and visual hallucinations. The patient had apparently not sought medical attention since the birth of her last daughter 30 years prior to this presentation. She had always been noted by family members to be somewhat reclusive but still engaged in many normal activities. One year prior to presentation, she was noted to have decreasing vision in her left eye, first at night and then progressing to decreased vision during the day. Her vision loss slowly progressed over the year and eventually began to involve both eyes. The patient continued to refuse medical care primarily related to a compelling fear of hospitals. In the 2 weeks before her presentation, she was noted by family to have developed some auditory hallucinations that she described as a voice inside her head telling her a variety of things; most notably she would hear voices of game show hosts or radio announcers. These symptoms persisted, and she started to note visual hallucinations as well. She had also resisted medical care for these issues but was finally convinced on the day of admission to seek medical attention as her visual and auditory hallucinations had worsened.

At the emergency department, Ms. A’s vital signs included a temperature of 97.7°F (36.5°C), a pulse of 60 beats/min, and blood pressure of 175/89 mm Hg. Findings of her physical examination were remarkable for dry skin with dry and brittle hair. Findings of her heart and lung examinations were unremarkable, and she had a normal-size thyroid gland. Her neurologic examination was notable for normal strength in all extremities with a significant delay in the relaxation phase of her deep tendon reflexes. She was awake, alert, and conversant but with notable auditory hallucinations during the examination.

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The patient was admitted to the hospital for further workup. Ensuing evaluation revealed laboratory values remarkable for a thyroid-stimulating hormone (TSH) level of 43.79 µU/mL, repeat TSH level of 53.13 µU/mL (reference range: 0.50-5.00 µU/mL), thyroxine (T4) level of less than 1.0 µg/dL (reference range: 4.5-10.9 µg/dL), and total triiodothyronine (T3) level of 24 ng/dL (reference range: 60-181 ng/dL). A noncontrast enhanced head computed tomography study showed mild small-vessel ischemic changes and no other abnormalities. A subsequent magnetic resonance imaging study of her brain revealed nonspecific periventricular white matter changes. The patient was started on low-dose thyroid replacement therapy. She was also started on a low dose of risperidone to treat the hallucinations. Her auditory and visual hallucinations slowly began to disappear, and, by 2 to 3 weeks into therapy, the patient had no further psychiatric symptoms.

Ms. A self-discontinued risperidone after 2 weeks with no reoccurrence of her psychiatric symptoms. Her loss of bilateral vision was thought to be due to dense cataracts, which were confirmed on further examination by the neuro-ophthalmology service and were removed, with subsequent return of her vision. At follow-up, Ms. A remained stable and euthyroid on thyroid replacement and an antihypertensive regimen. Ms. A was able to resume all regular activities with her family without apparent sequelae.

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