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Acute Psychotic Episode Due to Milk-Alkaline Syndrome
- Suraju Adeyemo, John Erfani, Attique Shafiq, Collins Chukwuma, Mark Worthington
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S117
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- Article
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Aims/ Background
: Milk-alkali syndrome is a medical condition, which could present with psychiatric manifestations. It is caused by hypercalcemia resulting from the ingestion of large amounts of calcium and absorbable alkali. The core symptoms include hypercalcemia, metabolic alkalosis, and renal failure. Diagnosing this syndrome requires a high index of suspicion. The aim of this paper is to describe the case of Mrs. C who had psychotic symptoms because of Milk-Alkaline syndrome
Methods/ Case ReportMrs. C was a 75-year-old white British female with a previous history of anorexia nervosa who has been clinically stable for more than 15 years. She was discharged by the community mental health services about 11 years ago but has been on a repeated dose of Gaviscon for about 8 years.
She presented to the accident and emergency (A and E) unit with a history of confusion, unsteadiness, paranoid beliefs, low mood, and reduced rate of speech. No history of infection or other physical health concerns. Routine blood showed increased calcium 3.41(2.2-2.60) and a reduced potassium level 2.9 (3.5-5.3). CT head scan did not show any acute changes.
She was stabilized and transferred to the ward for further management.
While on the ward, she had a diagnosis of Milk-Alkaline syndrome with psychiatric manifestation. Gaviscon was discontinued because the medics felt this was responsible for the electrolyte imbalance. She was also referred to the mental health liaison team (MHLT).
Following the mental health liaison team review, Mrs. C's psychiatric presentation was suspected to have been probably related to her medical condition. After a few weeks on the ward, her electrolyte became normalized; adjusted Ca 2.72 (2.2-2.6), serum ca 2.74(2.2-2.6). She had a follow-up review by the mental health team that showed her psychosis had also resolved. No medication was prescribed for her presentation. She was subsequently discharged from MHLT and referred to the GP for follow-up.
Results/ Discussionprevious case-report have shown a suspected link between Milk alkaline syndrome and acute psychosis, although the reasons for this have not been understood. The current case further emphasized this link. What is not evident however is if there were other physical health issues that might have also contributed to the patient's initial presentation.
ConclusionDiagnosis of Milk-Alkaline Syndrome requires a high index of suspicion, missing this could lead to inappropriate use of medication. As a psychiatrist, this case has shown the importance of adequate investigation before making a definitive diagnosis, especially in a psychiatric liaison setting.
Acute Psychosis in Hashimoto's Thyroiditis
- Suraju Adeyemo, John Erfani, Attique Shafiq, Collins Chukwuma, Charles Nwokonko, Mark Worthington
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S117-S118
-
- Article
-
- You have access Access
- Open access
- Export citation
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Aims
Hashimoto thyroiditis was discovered by Hakaru Hashimoto in 1912 but became more recognized in the 1950s. It is an autoimmune disorder with an incidence rate of about 0.8/1000/year in men and 3.5/1000/year in women. The inheritance pattern of Hashimoto thyroiditis is not fully understood and diagnosing this condition could be challenging. Among many presentations, its effects on mental health can lead to a greater burden on a patient. There has been an increased report of acute psychiatric symptoms in this condition. Literature has described a wide spectrum of psychiatric manifestations occurring prior to, during, and after this illness. The aim of this report is to describe a woman with diagnosed psychosis secondary to Hashimoto's thyroiditis.
MethodsMs S is a 22-year-old female who was admitted in January 2021 to the emergency department of Hospital B with a history of sudden behavioural changes: agitation, responding to unseen stimuli, and bizarre behaviour.
Her previous record reveals that she had a similar presentation in November 2019, managed with antipsychotics. The diagnosis at the time was unclear however; meningoencephalitis was suspected and later for NDMA encephalitis. After 4 months of admission to Hospital A, her behavioural changes remained unresolved but she was discharged to a care home with 2:1 support. She remained in the care home until further deterioration, which warranted a further admission to Hospital B.
Following a psychiatric review in Hospital B, she was initially diagnosed with an Acute psychotic episode with query cause and managed with IM Aripiprazole.
Due to physical health concerns and the unclear nature of her diagnosis, she was transferred to the acute medical ward and further investigation was requested.
Her result showed significantly elevated Thyroid Peroxidase Antibodies of 845 IU/ml (normal up to 24 IU/ml), lumbar puncture and NMDA antibody test were both normal, TSH level was raised to 6.73. Following further discussion with the medical team, a diagnosis of Psychosis secondary to Hashimoto's thyroiditis was made.
She was co-managed by the psychiatrist, endocrinologist and others.
Ms S became settled but due to residual psychosis, she was transferred to an inpatient psychiatric ward where her psychosis resolved, and was discharged back to the community mental health services.
Results/DiscussionAs a result of the late diagnosis of her condition and delayed hospital stay, Ms. S developed a lot of mistrust for the services as she believe that the 19-month delay had significantly impacted her quality of life.
ConclusionDiagnosis of psychosis secondary to Hashimoto's thyroiditis requires a high index of suspicion, missing this could lead to inappropriate use of medication and increased mobility.