From hormone deficit to hallucinations—severe hypocalcemia due to hypoparathyroidism presenting with acute psychosis: a case report

Psychosis is an uncommon manifestation of hypoparathyroidism and may result from severe hypocalcemia. Hypocalcemia can produce a range of neuropsychiatric disturbances, including cognitive impairment, mood symptoms, and, rarely, psychosis. Recognizing this association is important, especially in patients with a history of thyroid surgery. A 46-year-old South Asian woman presented with a 2-month history of progressively worsening hallucinations. She initially heard the voice of her deceased spouse at night, which later became continuous and was accompanied by visual hallucinations, fearfulness, poor sleep, and a marked decline in daily functioning. She had a history of total thyroidectomy and had been non-adherent to prescribed calcium, vitamin D, or thyroxine supplementation. On examination, she showed clinical features suggestive of hypocalcemia. Mental status examination revealed second-person auditory hallucinations and visual hallucinations, with partial insight, and preserved higher cognitive functions. Laboratory investigations demonstrated hypocalcemia, hyperphosphatemia, and undetectable parathyroid hormone levels. Computed Tomography of the brain showed bilateral calcifications in the basal ganglia and cerebellum. A diagnosis of psychosis secondary to severe hypocalcemia due to hypoparathyroidism was made. The patient was restarted on thyroxine and received calcium and vitamin D supplementation along with antipsychotic treatment. Her hallucinations, sleep, and daily functioning improved within a week, and follow-up showed sustained remission. This case highlights severe hypocalcemia due to hypoparathyroidism as an important and potentially reversible cause of psychosis. Careful evaluation for metabolic abnormalities in patients presenting with new-onset psychosis is essential, as timely correction of the underlying biochemical disturbance can lead to rapid clinical improvement.