Endocrine Abstracts

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 TFT’s, her gender and age it was suspected that she was Grave’s 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, TFT’s 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 TFT’s as part of confusion screening.