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Case records of the Massachusetts General Hospital. Case 10-2015. A 15-year-old girl with Graves’ disease and psychotic symptoms.

Dr. Emily K. Gray (Psychiatry): A 15-year-old girl with Graves’ disease was admitted to this hospital because of psychotic symptoms. The patient had been well until approximately 3 months before the current admission, when intermittent dizziness, palpitations, near syncope, diaphoresis, polyuria, polydipsia, diarrhea, chest and abdominal pain, headaches, and increasing protuberance of the eyes developed. Eleven weeks before this admission, she was evaluated at school, at an emergency department of another hospital, and at her pediatrician’s office. She had hypertension, with a blood pressure of up to 168/86 mm Hg, and tachycardia, with a pulse of up to 126 beats per minute. A complete blood count and the erythrocyte sedimentation rate were normal, as were blood levels of electrolytes, calcium, glucose, total protein, albumin, total bilirubin, urea nitrogen, and creatinine. Screening of the blood for toxins, Lyme disease, and antibodies against thyroglobulin, microsomes, and thyroperoxidase was negative, as was a urine pregnancy test; other test results are shown in Table 1. A few days later, 10.5 weeks before this admission, she was seen in the endocrinology clinic of this hospital. On evaluation, the patient reported no intolerance to heat or cold, tremor, or weight loss. She had had anemia as an infant and had undergone a cholecystectomy for cholelithiasis at 14 years of age. Menarche occurred at 11 years of age. She took no medications, her immunizations were up to date, and she had no known allergies. She was born in the Dominican Republic and came to the United States at 6 years of age. She lived with her parents, maternal grandmother, and two sisters. She was enrolled in an individualized education program in high school. She did not smoke, drink alcohol, or use illicit drugs. Her mother had celiac disease, a paternal aunt had hypothyroidism, her paternal grandmother had vitiligo and had undergone a thyroidectomy, and her father and siblings were healthy. On examination, the blood pressure was 110/72 mm Hg, and the pulse 114 beats per minute; the temperature and respiratory rate were normal. The height was 166.3 cm, the weight 81.1 kg, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) 29.3. Proptosis, a pronounced From the Departments of Psychiatry (E.P.H.), Pediatrics (N.A.S.), Surgery (S.P.), Radiology (C.A.R.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Psychiatry (E.P.H.), Pedi‐ atrics (N.A.S.), Surgery (S.P.), Radiology (C.A.R.), and Pathology (P.M.S.), Harvard Medical School — both in Boston.