SFEEU2023 Society for Endocrinology Clinical Update 2023 Workshop C: Disorders of the thyroid gland (16 abstracts)
Worthing Hospital, Worthing, United Kingdom
History: 72 yr. Female, Initially presented to A&E with new confusion and speech disturbance. NEWS of 7- RR 22, sats- 98% on RA, BP 162/107, HR-124, and T- 37. AMTS- 7/10. PMH: depression, previous dysphasia, Medication: Amitriptyline, Omeprazole.
Investigations: FBC, UE, LFT, CRP, Cholesterol levels, urine dip Normal and CT head normal. ECG Sinus tachycardia. Observations improved and no obvious cause found for confusion patient was discharged home from A&E with safety advice given to her daughter. Readmitted to ED two days later with worsening confusion, agitation, excessive sweating.
Observations: News 5, RR 24, O2 -96% on RA, HR 132, BP 160/90, T 37.4. At this point her AMTS had deteriorated to 1/10. Examination: Warm peripheries, delirious, tremulous, no obvious Eye signs, slightly enlarged thyroid gland, no visible rash Investigations: Confusion screen including TFT, LP. Treated empirically with IV Ceftriaxone and Acyclovir for possible encephalitis Investigations done: Adj Ca- 2.63 (2.20-2.60) Folate 15 B12 680 TSH - <0.03 (0.35 - 4.94) FT4 40.7 (9 19) FT3 18.1 (2.6 5.7), CSF Normal, Viral PCR pending, NMDA receptor antibodies negative Endocrine review :Given the deranged TFTs, her gender and age it was suspected that she was Graves disease, requested for TPO and TSH receptor antibodies which were later found to be high TPO Abs 163.96 (0 5.9), TRAB 51 (0 3.3) Treated with Carbimazole 30 mg OD, Propranolol 10 mg TDS, IV fluids. The following day patientwas not eating and drinking, worsening delirium, more agitated, hallucinating and few episodes of low grade pyrexia, with one temp spike above 38. According to the criteria on the Burch and Wartofsky scoring system. She was scoring 5 for temperature, 20 for delirium, 10 for tachycardia, scoring a total of 35. Treated as impending thyroid storm/ severe thyrotoxicosis with Hydrocortisone 100 mg IV QDS, Propranolol 40 mg TDS, Propylthiouracil 100 mg QDS, IV Fluids, NG feeding. Ceftriaxone was stopped but IV acyclovir was continued until CSF PCR results were normal. In a few days delirium started to resolve, TFTs began to improve, heart rate normalised. PTU was weaned to 100 mg TDS and hydrocortisone was weaned too. On day 17 of her admission, FT3 and FT4 normalised, (TSH still <0.03, which is expected), safely discharged home with endocrine outpatient appointment. Reviewed in outpatient clinic, patient well and currently on PTU 50 mg BD with a view to wean.
Conclusion: This case highlights the importance of checking TFTs as part of confusion screening.