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Vomiting and Hiccup as the First Presentation of Thyrotoxicosis
CLINICAL COMMUNICATION TO THE EDITOR
Vomiting and Hiccup as the First Presentation of Thyrotoxicosis To the Editor: Protean manifestations of thyrotoxicosis depend on its severity and duration, as well as the age of the patient. We describe an elderly thyrotoxic patient presenting with unusual manifestations, vomiting and hiccup, leading to a delay in diagnosis and treatment. Proposed pathogenesis and treatment are also discussed.
CASE REPORT A 76-year-old man presented with several episodes of vomiting and a 15-kg weight loss over the past 3 months. The vomiting was not related to meals and did not respond to symptomatic treatment. His symptoms worsened and were complicated with intractable hiccups. He denied diarrhea, abdominal pain, heat intolerance, or palpitation, but he noted constant fatigue. Investigation results, including gastrointestinal endoscopy, abdominal ultrasonography, and magnetic resonance imaging of the brain, were unremarkable. Examinations revealed cachexia and tachycardia. His diffusely enlarged thyroid gland was approximately twice the normal size with bruit. Other physical findings were unremarkable except for bilateral gynecomastia with mild tenderness. Graves’ disease was confirmed by elevated thyroid function tests (FT4 3.75 ng/dL, normal, 0.8-1.8; FT3 10.77 pg/mL, normal, 1.6-4.0; thyroid stimulating hormone <0.005 mIU/mL, normal, 0.3-4.1) and increased radioiodine uptake. Propylthiouracil 1200 mg/d and propranolol 40 mg/d were administered initially. Vomiting and hiccups dramatically improved 1 day after the addition of 4 mg/d of intravenous dexamethasone. His thyroid status was well controlled with propylthiouracil 600 mg/d. In addition, his estradiol levels also decreased from 118.7 to 89.6 pmol/L (normal, 0-130
Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Thiti Snabboon, MD, Samakki Phayabarn Building, King Chulalongkorn Memorial Hospital, Division of Endocrine and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Patumwan, Bangkok 10330, Thailand. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
pmol/L) during the follow-up period. Three months later, similar symptoms and transiently elevated estrogen levels reoccurred during the medication-free period needed for I-131 therapy but quickly receded with high-dose propylthiouracil and dexamethasone. Since then, the patient remains free of symptoms with complete resolution of his gynecomastia.
DISCUSSION Gastrointestinal manifestations, including hyperphagia or frequent defecation, often coexist with other thyrotoxic symptoms. Vomiting also has been mentioned; however, currently, with better control of thyroid dysfunction and earlier diagnosis, this has been reported only among severe cases.1 Vomiting can present intermittently or persistently and typically fails to respond to usual antiemetic medications. The only clue to the diagnosis for our patient, as well as in other reported cases, was the persistent tachycardia. The pathogenesis of vomiting in thyrotoxicosis is elusive. The absence of other gastrointestinal symptoms and negative gastrointestinal study results raise the possibility of a stimulation of the chemoreceptor trigger zone, similar to other metabolic disorders. Human chorionic gonadotropin, thyroid hormone, and estrogen have been proposed to play a central role in this manifestation. Changes in estrogen levels from high aromatase activity documented in the thyrotoxic attack were believed to be responsible for the emesis in our case, given the normal human chorionic gonadotropin level, poor response to beta-blockers, and new-onset gynecomastia. An increase in estrogen may result in nausea and vomiting in susceptible subjects. Of note, estrogen increases progressively throughout pregnancy, but vomiting occurs mainly in the first trimester, perhaps because of gradual desensitization. Hiccup, a sudden contraction of the diaphragm, is rarely referred to as a thyrotoxic manifestation. Hiccup has been associated with central nervous system disorders, injury to the phrenic or vagus nerve, and toxic or metabolic disorders affecting the central or peripheral nervous systems. Hiccup in our patient was likely caused by his surreptitious vomiting because of their concurrence. Vomiting in thyrotoxicosis responds to the peripheral blockade of thyroid action at the target tissues. Review of the literature shows that steroids are more potent than betablockers in controlling thyrotoxicosis-related vomiting.2 The dosage of dexamethasone for emesis is 4 to 8 mg/d, similar to that for thyroid crisis.
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The American Journal of Medicine, Vol 128, No 5, May 2015
CONCLUSIONS We report atypical presentations of thyrotoxicosis, namely, thyrotoxic emesis and hiccups, to raise awareness for clinicians. Suwimon Jearraksuwan, MDa Vitaya Sridama, MDa Paisith Piriyawat, MDb Thiti Snabboon, MDa a
Hormonal and Metabolic Disorders Research Unit Division of Endocrinology and Metabolism Department of Medicine Faculty of Medicine Chulalongkorn University
King Chulalongkorn Memorial Hospital Bangkok, Thailand b Department of Neurology Texas Tech University Health Sciences Center El Paso El Paso
http://dx.doi.org/10.1016/j.amjmed.2014.11.032
References 1. Ebert EC. The thyroid and the gut. J Clin Gastroenterol. 2010;44: 402-406. 2. Bondok RS, El Sharnouby NM, Eid HE, Abd Elmaksoud AM. Pulsed steroid therapy is an effective treatment for intractable hyperemesis gravidarum. Crit Care Med. 2006;34:2781-2783.
Vomiting and Hiccup as the First Presentation of Thyrotoxicosis To the Editor: Protean manifestations of thyrotoxicosis depend on its severity and duration, as well as the age of the patient. We describe an elderly thyrotoxic patient presenting with unusual manifestations, vomiting and hiccup, leading to a delay in diagnosis and treatment. Proposed pathogenesis and treatment are also discussed.
CASE REPORT A 76-year-old man presented with several episodes of vomiting and a 15-kg weight loss over the past 3 months. The vomiting was not related to meals and did not respond to symptomatic treatment. His symptoms worsened and were complicated with intractable hiccups. He denied diarrhea, abdominal pain, heat intolerance, or palpitation, but he noted constant fatigue. Investigation results, including gastrointestinal endoscopy, abdominal ultrasonography, and magnetic resonance imaging of the brain, were unremarkable. Examinations revealed cachexia and tachycardia. His diffusely enlarged thyroid gland was approximately twice the normal size with bruit. Other physical findings were unremarkable except for bilateral gynecomastia with mild tenderness. Graves’ disease was confirmed by elevated thyroid function tests (FT4 3.75 ng/dL, normal, 0.8-1.8; FT3 10.77 pg/mL, normal, 1.6-4.0; thyroid stimulating hormone <0.005 mIU/mL, normal, 0.3-4.1) and increased radioiodine uptake. Propylthiouracil 1200 mg/d and propranolol 40 mg/d were administered initially. Vomiting and hiccups dramatically improved 1 day after the addition of 4 mg/d of intravenous dexamethasone. His thyroid status was well controlled with propylthiouracil 600 mg/d. In addition, his estradiol levels also decreased from 118.7 to 89.6 pmol/L (normal, 0-130
Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Thiti Snabboon, MD, Samakki Phayabarn Building, King Chulalongkorn Memorial Hospital, Division of Endocrine and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Patumwan, Bangkok 10330, Thailand. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
pmol/L) during the follow-up period. Three months later, similar symptoms and transiently elevated estrogen levels reoccurred during the medication-free period needed for I-131 therapy but quickly receded with high-dose propylthiouracil and dexamethasone. Since then, the patient remains free of symptoms with complete resolution of his gynecomastia.
DISCUSSION Gastrointestinal manifestations, including hyperphagia or frequent defecation, often coexist with other thyrotoxic symptoms. Vomiting also has been mentioned; however, currently, with better control of thyroid dysfunction and earlier diagnosis, this has been reported only among severe cases.1 Vomiting can present intermittently or persistently and typically fails to respond to usual antiemetic medications. The only clue to the diagnosis for our patient, as well as in other reported cases, was the persistent tachycardia. The pathogenesis of vomiting in thyrotoxicosis is elusive. The absence of other gastrointestinal symptoms and negative gastrointestinal study results raise the possibility of a stimulation of the chemoreceptor trigger zone, similar to other metabolic disorders. Human chorionic gonadotropin, thyroid hormone, and estrogen have been proposed to play a central role in this manifestation. Changes in estrogen levels from high aromatase activity documented in the thyrotoxic attack were believed to be responsible for the emesis in our case, given the normal human chorionic gonadotropin level, poor response to beta-blockers, and new-onset gynecomastia. An increase in estrogen may result in nausea and vomiting in susceptible subjects. Of note, estrogen increases progressively throughout pregnancy, but vomiting occurs mainly in the first trimester, perhaps because of gradual desensitization. Hiccup, a sudden contraction of the diaphragm, is rarely referred to as a thyrotoxic manifestation. Hiccup has been associated with central nervous system disorders, injury to the phrenic or vagus nerve, and toxic or metabolic disorders affecting the central or peripheral nervous systems. Hiccup in our patient was likely caused by his surreptitious vomiting because of their concurrence. Vomiting in thyrotoxicosis responds to the peripheral blockade of thyroid action at the target tissues. Review of the literature shows that steroids are more potent than betablockers in controlling thyrotoxicosis-related vomiting.2 The dosage of dexamethasone for emesis is 4 to 8 mg/d, similar to that for thyroid crisis.
e6
The American Journal of Medicine, Vol 128, No 5, May 2015
CONCLUSIONS We report atypical presentations of thyrotoxicosis, namely, thyrotoxic emesis and hiccups, to raise awareness for clinicians. Suwimon Jearraksuwan, MDa Vitaya Sridama, MDa Paisith Piriyawat, MDb Thiti Snabboon, MDa a
Hormonal and Metabolic Disorders Research Unit Division of Endocrinology and Metabolism Department of Medicine Faculty of Medicine Chulalongkorn University
King Chulalongkorn Memorial Hospital Bangkok, Thailand b Department of Neurology Texas Tech University Health Sciences Center El Paso El Paso
http://dx.doi.org/10.1016/j.amjmed.2014.11.032
References 1. Ebert EC. The thyroid and the gut. J Clin Gastroenterol. 2010;44: 402-406. 2. Bondok RS, El Sharnouby NM, Eid HE, Abd Elmaksoud AM. Pulsed steroid therapy is an effective treatment for intractable hyperemesis gravidarum. Crit Care Med. 2006;34:2781-2783.