Pitfalls of the four hour wait: keeping alert to potential endocrine presentations in Accident and Emergency
Elena Cattaneo, Catherine Ann Hockings, Eleanor Foley, Matthew James & Jackie Buck
Background: Emergency staff are under pressure to assess and refer within tight targets. Two adolescents presented to A&E with psychiatric symptoms, were referred to Child and Adolescent Mental Health (CAMH), but fortunately came to our attention and were diagnosed with thyroid disorders.
Case 1: Fifteen-year-old boy presented with a two week history of disturbing auditory hallucinations and was referred to CAMH. He was commenced on antipsychotic medication. The A&E doctor did ask for a Paediatric opinion as he was lacking facial hair. OE Ht < 0.4th C, Wt >25th C, facial features of myxoedema, smooth goitre, sparse dry hair and bilateral hydroceles. Investigations: TSH > 150 miu/l (0.255), FT4 4 pmol/l (923), TPO antibodies > 1000 iu/l. The antipsychotic medication was stopped, he was treated with thyroxine and his hallucinations resolved.
Case 2: Fourteen-year girl presented with panic attacks, anxiety, auditory hallucinations and compulsive behaviour. CAMHs staff commenced Sertraline. At her routine asthma follow up HR was 120 bpm, proptosis, goitre and tremor. Investigations TSH < 0.1 miu/l, FT4 > 100. Within three months of carbimazole her psychiatric symptoms resolved.
Discussion: Although it is well recognized that adults presenting with acute psychotic symptoms may have thyroid disease, there does not appear to be the same recognition in children. Previous studies have indicated that the yield from routine screening TFTs in Paediatric Psychiatry patients is low and that no clear correlation appears to exist between psychiatric presentation and degree of severity in thyroid dysfunction. However, all health care professionals should be alert to patients who have additional symptoms and signs of thyroid disorders, particularly goitre. Appropriate treatment usually results in resolution of psychiatric symptomatology.