Primary Hyperparathyroidism Causing Psychosis: A Case Report

Abstract

New-onset psychotic symptoms presenting late in life can be caused by various medical and psychiatric conditions. The index of suspicion for an organic cause for psychotic symptoms in an elderly person should be high, and every presenting patient should undergo a detailed history-taking and evaluation before attributing these symptoms to a primary psychiatric condition. Hyperparathyroidism is one condition that can present with psychiatric symptoms such as low mood and anxiety. While psychiatric symptoms are not uncommon in hyperparathyroidism, acute psychosis is rare. This case report highlights the importance of a thorough evaluation of an elderly person presenting with a new onset of psychosis.

Primary Hyperparathyroidism in Older Adults: A Narrative Review of the Most Recent Literature on Epidemiology, Diagnosis and Management

“…Interestingly, short-term normalization of hypercalcemia via calcimimetic treatment and subsequent improvement in depression and anxiety symptoms (according to the Hospital Anxiety and Depression Scale) are good predictors of long-term outcomes after 6 months of parathyroidectomy, especially at the level of the cognitive response (according to the Montreal Cognitive Assessment) and therefore aid in an appropriate patient selection for surgery [46]. It is worth noting that improvement in neurological and psychiatric symptoms following parathyroidectomy was also supported by some case reports [28,[30][31][32]. Despite the evidence-based positive outcomes, parathyroidectomy is still underused for symptomatic PHPT in older adults [47].…”

“…A total of 29 articles met the inclusion criteria (Table 1). The studies break down as follows: 5 studies emphasized the epidemiology [7,[23][24][25][26], 8 studies were available with regard to the clinical manifestations [25,[27][28][29][30][31][32][33], 25 studies addressed the treatments [7,15,[23][24][25][27][28][29][30][31][32][34][35][36][37][38][39][40][41][42][43][44][45][46][47], and 7 considered the post-operative complications [7,25,26,37,44,48,49]. The Joanna Briggs Institute (JBI) critical appraisal tool was used to assess the methodological quality of the included studies and the data are presented in Appendix A (Tables A1-A4).…”

“…Patients can also exhibit cognitive, affective, and behavioral manifestations as well as movement disorders [25,[28][29][30][31][32] with even mild hypercalcemia [33]. Neuropsychiatric symptoms include memory loss, disorders of consciousness, sleep disturbance, fatigue, anxiety, and depression, as well as manic, psychotic, and obsessive-compulsive symptoms, among others.…”

Acute Psychosis Related to Primary Hyperparathyroidism in a Patient With Bipolar Disorder

“…The key differential diagnosis in this patient was a psychotic disorder, schizoaffective disorder, schizophrenia, bipolar II disorder, bipolar I disorder with psychotic features, and any other medical pathology contributing to these symptoms. Patients with hypercalcemia can present with a variety of psychiatric sequelae that ranges from anxiety and mood disorders to cognitive disorders [ 2 ]. Hyperparathyroidism is being detected and diagnosed more frequently with the advent of newer imaging techniques and laboratory tests [ 6 ].…”

“…This is usually caused by a solitary parathyroid adenoma, and the reported incidence is 21 cases per 100,000 person-years [ 1 ]. Hypercalcemia is a common clinical condition, and risk factors include primary hyperparathyroidism, various sporadic and genetic conditions, renal failure, and medications such as calcium, vitamin D supplements, vitamin A, thiazide diuretics, lithium, parenteral nutrition, theophylline, foscarnet, growth hormone, omeprazole, aromatase inhibitors, parathyroid hormone (PTH) analogs [ 2 ]. Patients suffering from PHPT may present with a complex set of skeletal, renal, and psychiatric symptoms; however, psychiatric symptoms are not considered an indication for surgery [ 3 ].…”