Symptoms of levothyroxine overdose may vary depending on age, metabolism, etc. There are no specific guidelines for treating levothyroxine poisoning. Here, we present the case of a 69-year-old man with a history of panhypopituitarism, hypertension, and end-stage renal disease who attempted suicide by ingesting 60 tablets of 150 µg levothyroxine (9 mg). Upon presentation to the emergency room, he was asymptomatic despite the free thyroxine level above the range of the assay. During the hospital stay, he developed sinus tachycardia, which was controlled with propranolol. Mild elevations in liver enzymes were also noted. He received stress-dose steroids; hemodialysis was performed a day earlier, and cholestyramine was administered. Thyroid hormone levels started to improve by day seven and finally normalized in 20 days, after which the home dose of levothyroxine was resumed. The human body has several mechanisms to compensate for levothyroxine toxicity, including the conversion of excess levothyroxine to inactive reverse triiodothyronine, increased binding to thyroid-binding globulin, and hepatic metabolism. This case shows that it is possible to have no symptoms even with an overdose of up to 9 mg a day of levothyroxine. Signs and symptoms of levothyroxine toxicity may not appear for several days after ingestion, and, therefore, close observation preferably on a telemetry floor is recommended until the thyroid hormone levels start to decrease. Effective treatment options include beta-blockers preferably propranolol, early gastric lavage, cholestyramine, and glucocorticoids. While hemodialysis has a limited role, antithyroid drugs and activated charcoal are ineffective.

Background: Amidst the COVID-19 pandemic, nursing home residents have seen a significant increase in hospitalizations. However, there is a lack of published data on the healthcare provided to these individuals in community hospitals. This knowledge gap hinders our understanding and evaluation of the quality and outcomes of care received by nursing home residents when they are hospitalized for COVID-19 or other medical conditions. Furthermore, insufficient data is used to compare the clinical outcomes of COVID-19-related admissions from nursing facilities between small community hospitals and tertiary care facilities. It is essential to conduct further research to identify potential disparities, which may indicate an unequal burden of nursing facility referrals to less-resourced hospitals.Objective: We examined the characteristics of COVID-19-related deaths in a community hospital during the first surge of COVID-19 and calculated the proportion of patients who expired and were transferred from nearby nursing facilities.Method: We performed a retrospective review of all cases of COVID-19 admitted to a 160-bed community hospital in Connecticut from January 1, 2020, to August 1, 2020. One hundred seventy-seven patients with COVID-19 who were admitted to our hospital were included in this study. Seventy patients (70/177, 39.54%) were transferred from nearby nursing facilities. The primary objective of this study was to examine the clinical characteristics of COVID-19-related deaths in our community hospital during the first surge of COVID-19. We also calculated the proportion of patients who expired and were transferred from nearby nursing facilities.Results: Although the mortality rate in our community hospital was 15.23% (27/177), the majority of those who died were from nursing facilities (85.18%, 23/27). In contrast, mortality among the patients admitted from the community was 3.7% (4/107). The patients transferred from a nursing facility had 12.6 times higher odds of 30-day inpatient mortality or referral to hospice (95% CI, 4.1-38.5; p<0.001). Conclusion:The majority of COVID-19 deaths in our community hospital were due to nursing facility referrals. We hypothesize that this high mortality may reflect healthcare inequality due to the unequal burden of nursing facility referrals to less-resourced hospitals.