By Tedler D. Depaynos, MD
The low profile middle aged lawyer was becoming frustrated when he can no longer control his “withdrawal symptoms” with the “shots” he takes every morning especially when he appears in court. Actually he started experiencing his uncontrollable tremors which usually appear in the morning when he had greatly reduced his Fundador intake. He tried doubling his morning “shots” but it seems to have no effect. He was debating to return to his old habits if not for the fast heartbeats or “tachycardia” he was also experiencing. His colleagues commented that he appeared to be losing weight despite his voraciousness especially when they visit Sagada Lunch. He was also observed to be “perspiring” despite the chilly weather. Because of these, his two secretaries began to worry and insisted that he retire from his hard headedness and consult an MD even the one who is their chronic client.
He did not consult his chronic client because he was afraid of a long lecture. He consulted a young lady MD who appeared to be a fresh graduate who gave a clinical diagnosis of possible “hyperthyroidism” because of his “tachycardia”, irregular heartbeats or “arrhythmia”, his sweating problem and tremors despite his insistence that he is suffering from a “withdrawal” problem. She requested that he should have an ultrasound of his anterior neck to rule out any thyroid enlargement or “tumor” especially so that she felt no abnormality upon palpation. She also requested lab tests for thyroid hormones.
Insisting that his “alcoholic problem” is different from his “cardiac problem” the lawyer consulted a well known cardiologist for a second opinion who gave the same impression of “Toxic Goiter” or “Hyperthyroidism”. This was confirmed by his elevated thyroid hormones as detected in the laboratory. He was prescribed one of the standard anti-thyroid drugs which is suppose to decrease the secretion of thyroid hormones and propranolol which is usually prescribed to control the manifestations of excess thyroid hormones which is termed in general as “toxic manifestations”. He was advised to continue his high calorie diet and was also prescribed vitamins. He was also advised to cease taking his “shots” and to follow-up after 2 weeks which is a must when one is taking anti-thyroid drugs especially when one is just starting. Succeeding follow-ups depends on his response to the meds prescribed.
Most of the time, the excess thyroid hormones are secreted by an enlarged thyroid gland which may be diffused and smooth or multi-nodular. The former is called Grave’s Disease in medical parlance and the latter, Plummer’s Disease. In some instances a solitary nodule is detected just like in the UTZ of this patient which may be the culprit. The cause is complicated which is termed “immunologic.
Thyroid hormones control the body metabolism and when in excess the metabolism is likewise excessive. This is manifested by tachycardia, arrhythmia, increased perspiration, intolerance to heat and hyperactivity like tremors. The burning of calories is more than doubled so that there is continuing decrease in weight. In severe cases, gradual “bulging of the eyeballs” would be noticed and is termed “exopthalmia” which is more common in the so called Grave’s Disease. Luckily the “eyeball” enlargement in this patient was still negative. Complications may also occur which may be due to the toxic manifestations like heart failure, malnutrition and visual defects.
Because of the small “nodule” seen in the UTZ, the patient was referred then to a general surgeon who happened to be his chronic client.
Over cups of unsugared coffee, the surgeon agreed with the diagnosis and treatment of the cardiologist because the laboratory results were obvious. He advised him however that the treatment would just control the thyroid secretions but would not remove the source of the secretions which most probably was the thyroid “nodule”. In short he was advised eventual surgery once the toxic manifestations are controlled as confirmed by normal laboratory tests. Of course, the clearance of the cardiologist was required.
The patient was initially undecided because his secretaries read in the internet something about Radioactive Iodine Therapy or 131 Iodine. On his own initiative, he consulted an Endocrinologist who however, advised him that “131 Iodine is usually for super large goiter like in Grave’s Disease but for solitary nodule like his, surgery is preferred”. Of course, the advices of Endocrinologists are based on many other factors and individual cases are separately appraised.
The patient eventually underwent thyroidectomy and completely recovered with no more medicines. He no longer manifested the “tremors” which he thought to be due to “withdrawal symptoms”. He however, missed taking his “shots” and so to reward himself he upgraded his taste to the more expensive “Double”. **
