Case #2: A 50-year-old man presents with complaints of a fever and "feeling anxious." The patient has had a productive cough, subjective fever, and myalgias for 7 days. Yesterday, he began to "feel anxious" and like his "heart was racing." His pas medical history is significant for a goiter that is still being evaluated. His vital signs are respiratory rate of 18 respirations per min, blood pressure of 160/80 mm Hg, temperature 38°C (100.4°F), and heart rate 140 beats per min. On physical examination, you note that the patient appears nontoxic. He has a tender goiter, a fine tremor of his hands, and an irregular heart rhythm. On his lung examination, there are left midfield rales. You suspect community-acquired pneumonia, but the tender goiter introduces management concerns.
Case #1: You identify a left femoral neck fracture in the patient. With little clinical history, you try to determine the events of the past 3 days. You evaluate the patient for acute processes that may have caused a fall, such as intracranial hemorrhage, ischemic stroke, and myocardial infarction. You also evaluate the patient for sequelae of a simple trip and fall that may have left her with altered mental status, including intracranial hemorrhage and withdrawal from chronic medications. The well-healed scar on her anterior neck suggests that the patient had a thyroidectomy. Perhaps the patient fell, broke her hip, and subsequently was unable to access her levothyroxine to maintain her euthyroid state. The patient requires intubation because of her respiratory failure (respiratory rate of 10) and predicted clinical course, which is likely a prolonged recovery. After intubation, you evaluate her cardiac function and inferior vena cava with bedside ultrasound to assess her fluid status and her ability to tole ate a fluid bolus. She is hypovolemic but has reasonable left ventricular function. The ultrasound suggests that fluid resuscitation should improve her blood pressure without the use of vasopressors at this time. You administer levothyroxine intravenously. You notify the intensivist of a suspicion of myxedema coma due to the inability to access medications following a trip and fall with a resultant hip fracture. The intensivist promptly admits the patient and will contact the orthopedist to plan a repair when the patient is stable.
Case #2: The clinical presentation in this patient suggests pneumonia, which is confirmed by a focal infiltrate on his CXR. Treatment of the fever with acetaminophen has little effect on his tachycardia. An ECG reveals atrial fibrillation. You suspect that the goiter is a thyroiditis, and this infection has worsened his hypothyroidism. A continuous intravenous infusion of a b-blocking agent rapidly improves the patient's tremor, anxiousness, and heart rate. You administer PTU orally. After about 1 h on a continuous infusion, the cardiac rhythm converts to a sinus rhythm at a rate of 88 beats per min. You wean the intravenous infusion, starts oral iodide, and begins an oral b-blocking agent. You demonstrate prompt response to therapy and has no comorbidities to require admission to the hospital for community-acquired pneumonia. The patient is a good candidate for discharge if appropriate follow-up can be arranged. You contact the primary care physician, who will see the patient tomorrow and who tells the emergency clinician that the patient is also in the care of an endocrinologist with whom the primary physician works closely. The patient is comfortable with the plan for outpatient management and happy with the dramatic improvement in his symptoms.
Both of these cases allow reflection on the common occurrence of dual diagnoses in thyroid crises. Without a good index of suspicion, the thyroid crises could have been overlooked. These cases reinforce the importance of taking in the entire clinical picture and looking beyond the obvious initial diagnosis.