What's Your Diagnosis? Managing Patients with Thyroid Emergencies

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Emergency Department Management of Patients With Complications of Chronic Neurologic Disease correct.

Case Presentation: Emergency Department Management of Patients With Thyroid Emergencies

A 67-year-old woman presents to the emergency department by EMS with altered mental status…

According to EMS, a family member found her at home, without heat, with an outdoor ambient temperature of 36°F. She was in a confused mental state.
On EMS arrival, the patient was noted to be obtunded, with a temperature of 31.6°C, heart rate of 43 beats/min, blood pressure of 78/45 mm Hg, and respiratory rate of 15 breaths/min.
In the ED, you note the patient to be cold and minimally responsive.
Review of her medical record shows she currently takes lisinopril, atorvastatin, levothyroxine, and citalopram. Because the differential diagnosis for this patient is so broad, you wonder whether her medication list provides any clues…

Case Conclusion

You evaluated the patient for other causes of her altered mental status, including intracranial bleed, acute ischemic stroke, sepsis, and myocardial infarction. You initiated fluid resuscitation, applied warm blankets, and started a sepsis workup and broad-spectrum antibiotics. Her ECG was notable for sinus bradycardia, with no signs of ischemia. You obtained a CT of the head without contrast and angiography studies, and they were both negative for acute bleed or stroke.

The patient’s son arrived and reported that he last saw the patient well 1 week ago, but he was unsure whether she had been taking her medications. You reassessed the patient and noted that her blood pressure had improved to 95/60 mm Hg, and her heart rate to 62 beats/min. Her mental status improved, and she was able to tell you her name and follow simple commands.

Her bedside echocardiogram showed moderately depressed left ventricular systolic function, no pericardial effusion, and a collapsible inferior vena cava. You were concerned for decompensated hypothyroidism and initiated IV levothyroxine in addition to stress-dose corticosteroids.

Given her tenuous presentation and your concern for decompensated hypothyroidism, you spoke to the intensivist who agreed to admit the patient to the ICU.