Endocrine Abstracts

1. A 48 year old female was admitted to inpatient psychiatry with paranoid delusions, auditory hallucinations and subsequently detained under the Mental Health Act of Scotland. She had been diagnosed with Graves’ Disease 5 years previously having presented with anxiety and weight loss but had elected to refuse anti-thyroid drugs in favour of homeopathy and acupuncture. She refused any treatment for Graves’ Disease when admitted to Psychiatry even though floridly thyrotoxic. She was found to have new atrial fibrillation with a ventricular rate of 153 beats/minute and was transferred to the Coronary Care Unit. Thyroid storm was confirmed using the Burch and Wartofsky scoring system where she scored 75 points given the presence of psychosis, tachycardia, atrial fibrillation and pulmonary oedema. 2. Thyroid function tests demonstrated thyrotoxicosis with a suppressed TSH, free T4 of 52 pmol/l and total T3 6.1 nmol/l. 3. Despite a multi-disciplinary approach including Psychiatry, Pharmacy, Cardiology and Endocrinology, the patient refused to consider any active treatment including covert Lugol’s iodine and amiodarone. As the mortality rate of thyroid storm is substantial at 10–30%, we elected for emergency thyroidectomy in her best interests. This was especially as there is some evidence that neuropsychiatric manifestations portend greater risk of mortality. The patient was intubated under the Adults with Incapacity Act of Scotland and then treated with nasogastric propylthiouracil, hydrocortisone, Lugol’s iodine and beta-blocker for 72 hours prior to surgery. She had a fraught post-operative period and remained intubated for 23 days with a tracheostomy formed on day 14 to aid weaning attempts. She sustained ventilator-associated pneumonia and a pulmonary embolism. She made a full recovery with remission of atrial fibrillation and improved psychiatric symptoms, allowing the short-term detention certificate to be revoked. Nine months later, she is managed with aripiprazole and accepts that her emergency treatments were reasonable. She is on 125 micrograms of levothyroxine with well controlled thyroid hormones. 4. Neuropsychiatric symptoms are common in patients with Graves Disease. This may have contributed to our patient’s years of non-compliance and ultimate thyroid storm with the florid encephalopathy and psychiatric findings described. This case highlights the necessity of a considered MDT approach with perioperative anti-thyroid medication for stabilisation. Sustained recovery of cardiovascular and psychiatric status can be achieved. Finally, mental health legislation supports clinicians in making difficult but essential treatment choices where the patient lacks capacity and life is at risk.