Hypothyroidism: A Silent Killer in Young Patients

Abstract

Hypothyroidism is considered by many as a "great mimicker" of many common complaints in the emergency department (ED). Thyroid disorders pose a significant threat when prolonged or in the acute presentation, and are potentially serious disorders with symptoms that range from non-specific constitutional to subtle or frank neuropsychiatric symptoms. Untreated disease can lead to myxedema crisis or coma, a life-threatening presentation that is rarely identified in young male patients and carries by itself a high risk of mortality, even in cases that undergo proper medical management. We present a case of a 26-year-old non-smoker Hispanic man with a medical history of hypothyroidism since the age of 13, and bronchial asthma. In a period of 3 -4 months, he developed generalized malaise, fatigue, cold intolerance and unintentional weight loss. He visited the ED after developing acute abdominal pain associated with non-bloody watery diarrheas. At the initial evaluation, vital signs revealed hypotension, borderline low heart rate, and hypoglycemia. On physical examination, he looked pale, appeared lethargic, with facial puffiness, macroglossia and bilateral hyporeflexia with delayed relaxation on muscle stretch reflexes. The laboratory results showed a thyroid stimulating hormone (TSH) of 314.75 uIU/mL. There was also low sodium and elevated creatinine and hepatic enzymes levels. Abdominopelvic CT scan incidentally revealed a large pericardial effusion that was later confirmed with echocardiogram. A diagnosis of myxedema crisis was established, prompt initiation of intravenous hydrocortisone, levothyroxine and triiodothyronine therapy was administered, and he was transferred to another institution for management of the pericardial effusion. This case raised concerns about the incidence where thyroid disease presentations are not identified and where patients fail to receive adequate medical therapy. We as primary care physicians should encourage patients to adhere to medical therapy and the recommended follow-up instructions to avoid catastrophic complications such as myxedema crisis.