Endocrine Abstracts

A 74-year-old gardener developed progressive dysphagia for solids and liquids over 15 months. He lost five stone in weight and became increasingly weak. There was nothing significant in his past medical and drug histories. He is married, never smoked and drank little alcohol.

He had an acute medical admission via A&E in April 2008 for profound dehydration and cachexia. His weight was 41.5 kg. There were no gross neurological deficits but he had hoarseness and his cough and swallow reflexes were impaired. His blood investigations showed raised liver enzymes and severe hyperthyroidism (TSH <0.01, T₄ 91.5) with a high thyroid stimulating hormone receptor antibody titre of 7.7 (0.0–0.4). Videofluoroscopy showed failed attempts to initiate swallow and a barium swallow was abandoned due to marked dysphagia and aspiration. A thyroid uptake scan revealed diffuse increased uptake in both lobes 14.15 (0.4–4.0) compatible with Grave’s thyrotoxicosis.

Given his low body weight and poor swallow, a PEG was inserted. He was initially treated with propranolol as well as carbimazole to which he had worsening liver function. Substituting propylthiouracil led to steady improvements in both liver and thyroid function tests. Most of his nutrition and drugs were given via the PEG for a year. His weight in July 2009 was 67.1 kg, BMI 23. The PEG was removed in August 2009. His recent thyroid function tests suggest mild hyperthyroidism (T₄ 17.4, T₃ 7.3 and TSH <0.01) and he is being prepared for radioactive iodine therapy.

This case describes a rare presentation of bulbar myopathy due to Grave’s thyrotoxicosis. Weight loss was his only classical manifestation of thyrotoxicosis, which perhaps contributed to a delay in his diagnosis. This emphasizes the importance of measuring thyroid function in all patients with illnesses associated with unexplained weight loss, muscle wasting and/ or weakness.