Endocrine Abstracts

Background: Thyrotoxic crisis is a rare and life threatening condition requiring urgent medical intervention. Intrahepatic cholestasis, hypoglycaemia and pancytopenia are known but uncommon presentations in thyrotoxic crisis.

Case presentation: A 71 year old Sri Lankan female with a background history of diabetes presented to a tertiary care centre with severe hypoglycaemic episodes despite being off oral hypoglycaemic agents, weight loss of 6 kg, palpitations and breathlessness over the preceding 3 months. She was a thin built lady with a BMI of 18.5 kgm^-2, temperature 99^oF. She appeared breathless on presentation with mild agitation. There was pallor, icterus, fine tremors, ankle oedema and evidence of hyperhidrosis. Jugular venous pressure was elevated. She had a non tender multinodular goitre, and pretibial myxoedema. Features of dysthyroid eye disease were absent. Her pulse was irregularly irregular at a rate of 120/min, a soft ejection systolic murmur was noted at the pulmonary region. There were bibasal crepitations. Electrocardiogram (ECG) confirmed the presence of atrial fibrillation. FT4 was elevated 6.4 ng/dL (0.89-1.76) with suppressed TSH 0.008mIU/l(0.55-4.78) suggestive of thyrotoxicosis. There was pancytopenia in the full blood count (white cells 3.2x10 ³ /ul, haemoglobin 6.8g/dl, platelets 78,000/ul). Liver enzymes were normal (AST of 44U/dl, ALT of 22U/dl), however conjugated hyperbilirubinemia was noted (total bilirubin 2.8 mg/dL(0.1-1.2 mg/dl), direct 1.0 mg/dL(<0.3 mg/dl). ALP was 220 IU/dL(44-147IU/dl), and gamma GT levels 193U/l(5-40U/l). Ultrasound scan of the abdomen revealed the presence of congestive hepatopathy and absent intra or extrahepatic bile duct dilatation. HbA1c was 4.4%. Fasting blood sugar was 56.8 mg/dL and premeal capillary blood sugar monitoring varied from 66-80 mg/dl. Renal functions were normal. Ejection fraction was 60% in echocardiogram. Chest X-ray showed bilateral lung congestion without cardiomegaly. Ultrasound scan of the neck demonstrated a multinodular goitre with increased vascularity, without retrosternal extension. Burch-Watorfsky score was 60 suggesting thyrotoxic crisis. She was initially bridged with lithium carbonate, Lugols iodine and cholestyramine due to the presence of hyperbilirubinaemia, but due to suspected Lithium toxicity Lithium had to be withheld after 1 week. Thereafter she was started on propylthiouracil which resulted in rapid improvement of thyroid function tests as well as pancytopenia and the intrahepatic cholestasis. She additionally required blood transfusions and diuretics to improve her symptoms.

Conclusion: Cholestasis, hypoglycaemia and pancytopenia are rare complications of thyrotoxicosis. Thionamides are a safe option of treatment with careful monitoring of blood counts and liver functions.