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Abstract: Hashimoto’s thyroiditis, also known as chronic lymphocytic thyroiditis, is also an autoimmune thyroiditis, and a small number of patients have hyperthyroidism early in the course of the disease, called Hashimoto’s hyperthyroidism. In this article, the patient presented with high fever, nausea, vomiting and diarrhea.
Basic information】Female, 45 years old
Type of disease】Hashimoto’s thyroiditis
Hospital】Beijing Hospital
Date of Consultation】May 2020
Treatment plan】Medication (potassium chloride injection, calcium gluconate injection, glucose injection, propylthiouracil tablets, propranolol hydrochloride tablets, hydrocortisone sodium succinate for injection)
Treatment period】10 days of inpatient treatment, 3 months of outpatient follow-up
Treatment effect】The disease has been controlled, and all indicators are improving
I. Initial consultation
Three days before admission, the patient developed fever after exertion, with a maximum temperature of 40℃, accompanied by panic, excessive sweating, nausea, vomiting, diarrhea and chest tightness, which did not improve after treatment by infusion (specific drugs not known) at the local hospital. The patient had a history of hypertension for more than 3 years and usually took oral captopril to lower blood pressure. Physical examination showed a body temperature of 39.4℃, pulse rate of 145 beats/min, respiration of 20 breaths/min, blood pressure of 160/80 mmHg, clear and depressed, no proptosis, thyroid gland II enlargement, no pressure pain, and no obvious vascular murmur was heard. He had clear respiratory sounds in both lungs, no dry or wet rales, neat heart rhythm, no pathological murmurs, flat and soft abdomen, no pressure pain, no pre-tibial mucous edema in both lower extremities, and was admitted with “high fever and acute gastroenteritis”.
II. Treatment history
After admission, the blood count was 8.9×10^9/L, 70% neutrophils and 25% lymphocytes; the urine and stool were normal; the 24h ECG showed sinus tachycardia and paroxysmal atrial fibrillation; the chest X-ray showed no abnormality in heart, lungs and diaphragm; the thyroid function showed FT3 69.4pg/ml (2.3-4.2), FT4 70.4pmol/L ( 11.5-22.7), TSH 0.09mIU/L (0.35-5.5), anti-thyroid peroxidase antibody (TPOAb) >1300IU/mL (0-34), thyroglobulin antibody (TgAb) >500IU/mL (0-115), thyroid ultrasound showed uneven echogenicity in the right and left lobes of the thyroid gland (Hashimoto’s thyroiditis) (see Figure 1 After admission to the hospital, the patient was immediately treated with cardiac monitoring, oxygen administration, 24-h volume monitoring, physical cooling, potassium chloride and calcium gluconate injection to maintain electrolyte balance, and glucose The patient was treated with physical hypothermia, potassium chloride injection and calcium gluconate injection to maintain electrolyte balance, and glucose injection for energy. After the diagnosis was confirmed, propylthiouracil tablets and propranolol hydrochloride tablets were given orally and hydrocortisone sodium succinate for injection was administered intravenously.
Figure 1
Figure 2
III. Treatment effect
After 3 days of treatment, the patient’s heart rate decreased to 89 beats/min and body temperature decreased to normal, and the clinical symptoms improved. Thereafter, propylthiouracil tablets were reduced to oral maintenance therapy, and injectable hydrocortisone sodium succinate was gradually reduced to 1 week and then discontinued. The patient was discharged from the hospital in 10 days, and thyroid function was normal on recheck 6 weeks after discharge.
IV. Notes
We are glad that after treatment the patient’s condition has been controlled and all indicators are improving. After discharge, the patient still needs to take small doses of antithyroid medication, so it is necessary to regularly review and monitor the thyroid function and adjust the dosage of antithyroid medication according to TSH, FT3, FT4 and other indicators. It is important to note that most patients with Hashimoto’s thyroiditis have transient hyperthyroidism, which may progress to hypothyroidism with subsequent destruction of thyroid tissue. Therefore, medications should be adjusted according to thyroid function levels, and if TSH rises, anti-thyroid medications should be discontinued in a timely manner, and even oral treatment with levothyroxine sodium tablets should be added.
V. Personal Insights
A small percentage of patients with Hashimoto’s thyroiditis have hyperthyroid symptoms early in the course of the disease, called Hashimoto’s hyperthyroidism. The actual fact is that you will be able to get a lot more than just a few of the most effective and most effective and most effective. However, in cases such as mental stimulation, infection and inadequate preparation for thyroid surgery, Hashimoto’s hyperthyroidism can also induce hyperthyroidism crisis, and if not rescued in time, the morbidity and mortality rate can reach 75%. The patient had not been treated regularly for Hashimoto’s thyroiditis in the past, but this case started with hyperthyroidism crisis, which is a critical condition. As the patient had gastrointestinal symptoms, it was easily misdiagnosed as acute gastroenteritis, so we must not ignore the inconsistencies between laboratory test results and vital signs and clinical symptoms, and fully consider all possibilities to avoid misdiagnosis.