Introduction: Thyrotoxic crisis is a rare endocrinological emergency with high mortality and it is more frequent in Graves disease.
Clinical case: A 66-year-old women with schizophrenia was admitted to the Emergency Department due to altered state of consciousness, fatigue, constant moaning interspersed with unusual psychomotor agitation, heteroaggressiveness, diarrhea and anorexia. Lack of compliance with her psychiatric medication, new delusional ideas or use of recreational substances or drugs were excluded. The patient presented with normal blood pressure, peripheral oxygen saturation of 100% but she was sweating, subfebrile (37.6ºC) and tachycardic (154 bpm) and had painful palpation of the left iliac fossa without peritoneal defense. She had bilateral pulmonary stasis and showed permanent restlessness. Abdominal ultrasound excluded intra-abdominal infection and chest X-ray excluded pneumonia but showed Kerley B lines. The electrocardiogram showed persistent sinus tachycardia with poor response to beta-blockers, digoxin, analgesia and antipyretic medication. She had slight elevation of hepatic cytolysis enzymes, normal bilirubinemia, slightly elevated CRP (2.25 mg/dL) without leukocytosis, normal amylasemia and negative cardiac markers. Due to persistent sinus tachycardia, thyroid function was requested and showed TSH <0.004 uIU/ml (0.4-4.0); free-T4 >5.0 ng/dL (0.7-1.5) and free-T3 >20 pg/mL (1.8-4.2). The diagnosis of thyrotoxic crisis was assumed with Burch-Wartofsky Scale of 60 points. The patient did not have any known thyroid disease. Propitiuracil, corticosteroids, cholestyramine and propranolol were started. She was initially stabilized in an Intermediate Care Unit due to congestive heart failure requiring non-invasive mechanical ventilation. The microbiological study was negative and no precipitating factor was found. TRABS and thyroid stimulating immunoglobulin were both detected: 9.7 U/l (< 1.0) and 1.0 U/l (<0.1) respectively. Thyroid ultrasound showed multinodular goiter with 2 larger nodules measuring 4 and 2 cm. She did not have Graves orbitopathy. The patient was discharged after clear improvement of thyroid hormones: free-T4 1.60 ng/dL (0.7-1.5); free-T3 3.6 pg/mL (1.8-4.2) and underwent total thyroidectomy a few months later.
Conclusion: Long-term, disabling schizophrenia with a predominance of negative symptoms led to the devaluation of initial complaints - interpreted as psychiatric decompensation. In fact this was the second time the patient went to the emergency department with the same symptoms of restleness and agitation without a obvious cause. The time between the onset of symptoms and diagnosis was 5 days. Fever, persistent tachycardia and the patients objective state of discomfort in the absence of appreciable analytical or ultrasound alterations led to the diagnosis.
21 May 2022 - 24 May 2022