By Tedler D. Depaynos, MD
It was when a rejected applicant for the police academy who was disqualified due to “hyperthyroidism” came for a second opinion that we were reminded of a previous patient who had the same diagnosis.
The patient was a well known lawyer who obviously was with tremors for even his voice as he was describing himself and presenting his complaint was with tremors. He thought initially it was due to “withdrawal symptoms” because he enjoys the Double Black nightly and when he feels the tremors the following late morning they disappear with a shot of his leftover the previous night. This became his almost routine especially when he has a court hearing for he does not like to look nervous with his uncontrolled tremors when facing the judge. He noticed recently however that even if he triples the shot, his tremors persisted. He also observed that he began perspiring profusely from to time, started losing weight which became noticeable when his pants covered by his expensive barong became loose and kept on sliding down his waist. When he suddenly experienced strong palpitations which became constant he was forced to seek consultation.
It was his secretary who initially noticed that his eyes appeared to be slightly bulging despite his insistence that it was just due to the thinning of his handsome face. Because of this, even an inexperienced medical intern, could tell that he was manifesting “thyrotoxicosis” or “hyperthyroidism” or goiter toxicity.
In most instances “hyperthyroidism” is accompanied by an enlarged thyroid gland or an apparent nodule which maybe baseball or marble like in size but in rare instances the anterior neck where the thyroid gland is located may look normal. Even on palpation if they are very small they sometimes cannot be felt. A large obvious nodule may be palpated but there may be others that could easily be missed like in this patient. An ultrasound of his anterior neck helped and localized the nodules that cannot be felt even by experienced hands.
Because the patient was always attributing what he felt to his nightly excessive habit, he never thought that he had “toxic goiter” until he manifested the excessive signs and symptoms especially the palpitations. The thyroid gland secretes hormones which control the body metabolism which in layman’s terms is production of energy for the body functions. With excess thyroid hormones there is excessive production of energy. The body becomes super active as manifested by palpitations, excessive perspiration due to excessive body heat, and the feeling that one is always on the go. On the process, fats and carbohydrates are excessively burned and the diet becomes deficient despite frequent intakes precipitated by constant hunger. The opposite where the hormones are lacking termed “hypothyroidism” is manifested by apparent feeling of “laziness”, increase in weight and non-perspiration. Lab tests for the thyroid hormones easily confirm the clinical diagnosis and this is what happened to the patient. In some cases, heart palpitations are the only early manifestation of toxic goiter so that cardiologists routinely request thyroid hormones tests to rule out its excessive secretion as the cause.
As a rule the whole thyroid gland secretes the hormones. In several cases, a nodule or a tumor which may be benign or malignant is the one responsible for the excessive secretion and this could easily be localized by ultrasound. Hence as part of the work-up of these patients this procedure is a must. For other more experienced and aggressive MDs they do a needle biopsy on the nodule to eliminate mainly malignancy.
The treatment of course starts with the control of the secretion of the excess thyroid hormone by the giving of prophylthiouracil (PTU) or methimazole. This is strictly monitored and it may take months of intake to control the disease. If the sign and symptoms are severe a beta blocker usually propranopol is given initially to control them and to make the patient comfortable. This is also strictly monitored and discontinued once the excess secretion of thyroid hormone is controlled.
Medical treatment is routinely done by most internists but this is actually the specialty of the endocrinologists who are available locally. If this is not effective the source of the excessive thyroid hormone may be destroyed by Radioactive Iodine 131. Thyroid surgery or thyroidectomy which basically removes part or all of the thyroid gland is basically not done until the “thyrotoxicosis” is controlled. The type of thyroidectomy if ever it would be done of course will depend on the evaluation of the surgeon.
Since toxic patients lose weight fast like this patient, intake of additional calories and vitamins is advised. The nightly habit that camouflaged his toxic condition should also be discontinued.
In this patient, his “thyrotoxicosis” was luckily controlled after many months of medical therapy. He started regaining his previous weight and his slightly bulging eyes also became normal. He refused to undergo, for the moment, surgery and preferred to continue his medical treatment. It was not clear however if he graduated permanently from his nightly excessive habit.**
