I was having some work done on my house last month and during his lunch break, one of the workers said to me when he found out I was a pulmonary and critical care doctor: “I’ll bet you’ve seen some things.” And like any doctor, I have. So, I decided to write a series of posts about some of the strange and unusual cases I’ve seen over the years. And I’m going to start off with two cases of hypothyroidism.
A case of catatonia
Back in 1984, I was an intern on the general internal medicine service and got called down to the ER one night to admit a 17-year-old girl with an enlarged heart. Her family had brought her to the hospital because her behavior had become increasingly erratic. For several years, she had been falling behind in school. She did not participate in school sports because she just didn’t have the energy to keep up with the other kids. For several weeks, she had been getting increasingly withdrawn and then earlier in the day had become completely unresponsive.
When she arrived at our ER, she was catatonic. You could hold her arm up and it would just stay there. She stared straight ahead without answering any questions. The ER resident diagnosed catatonic schizophrenia and called the psychiatry resident to admit her to the psychiatric hospital that was a part of our medical center. A routine admission chest x-ray was ordered and it unexpectedly showed an enlarged heart. The medical center policy was that if a psychiatric patient had any untreated medical condition, that patient would be admitted to one of the medical services on a med/surg unit and would be followed by the psychiatry consultation service until the medical condition was stabilized and then the patient would be transferred to the psychiatry hospital.
So, I went down to do her admission history and physical exam. Sure enough, she was stuporous and non-verbal. I could reposition her arms and legs and they would just remain in whatever position I put them. And she just didn’t look right – we used to call the look an “FLK” (funny looking kid) – you couldn’t put your finger on it but they just didn’t look quite right; many of them had genetic conditions. Her face was round and sort of puffy. She was short for a 17-year-old, less than 5 feet tall. And she seemed pudgy. Her eyelids appeared thickened and doughy, almost like they were swollen and her lips were large.
The next morning, we got an echocardiogram to evaluate the enlarged heart and found that she had an enormous pericardial effusion. In working up her effusion, we ordered a TSH test and it came greater than 100 mIU/L (normal is less than 4 mIU/L and highest level the lab reported was 100 mIU/L). TSH stands for thyroid stimulating hormone. TSH is made by the pituitary gland and signals the thyroid gland to make thyroid hormone. If the thyroid gland is not working properly, the pituitary responds by making more TSH to flog the thyroid into making more thyroid hormone. A level over 100 is incredibly high and indicates severe and long-standing hypothyroidism, one of the causes of a pericardial effusion.
We started her on thyroid hormone replacement – one of the few times I’ve given intravenous thyroid hormone. Within 3 days, she was talking normally, walking normally, and her pericardial effusion was improving.
As it turns out, she was actually diagnosed with congenital hypothyroidism as an infant and was started on oral thyroid hormone replacement therapy. Her pediatrician told her parents that she would need to take it for the rest of her life. But when she was a few years old, her grandmother (a religious zealot) proclaimed to the family that thyroid hormone replacement was a potion made by the devil to steal children’s souls. So, her parents stopped giving it to her. Over the years, she had stunted growth, had intellectual impairment, and developed a cretinoid appearance. All of that culminated in catatonia and a pericardial effusion from severe hypothyroidism.
After her discharge from the hospital, I followed her in our general medicine resident’s clinic for the next two and a half years. With re-initiation of daily thyroid hormone replacement therapy, she slimmed down, graduated from high school, and even did some modeling as her cretinoid facial appearance changed to that of a regular young woman’s. In other words, she became a normal person again. The moral of the story is that thyroid hormone replacement therapy is not made by the devil.
A case of prolonged coma
In the 1990’s, our hospital contracted with a long-term acute care hospital (LTACH) called Intensiva (Intensiva later became Select Specialty Hospitals). LTACHs were designated by Medicare to be specialized hospitals that cared for patients with long lengths of stay – in other words outlier patients who could not be discharged from a regular acute care hospital in a reasonable period of time. Regular acute care hospitals are paid by Medicare based on a patient’s DRG (diagnosis-related group), regardless of how many days they are in the hospital. LTACH’s specialize in caring for outlier patients who require hospital care for more than 30 days – Medicare would then pay the LTACH based on the number of days the patient required hospitalization instead of based on the patient’s diagnosis. Common conditions that resulted in admission to an LTACH were respiratory failure requiring prolonged weaning from a mechanical ventilator, complex would care, and infections requiring prolonged intravenous antibiotics.
Intensiva leased part of the 11th floor of our hospital. Our medical intensive care unit was on another part of the 11th floor so it made it easy to transfer patients from our MICU to Intensiva. Furthermore, Intensiva purchased certain services from our hospital, such as radiology and laboratory testing, making it easy to get diagnostic tests. Most of our hospital’s physicians got credentialed in Intensiva so that patients transferred from our hospital to Intensiva could have continuity of care by consultants. Because most of the patients admitted to Intensiva came from our MICU, we (the pulmonary and critical care physicians) were the primary attending physician for all of the patients in Intensiva. On occasion, we did get patients from our surgical intensive care unit or from other hospitals’ intensive care units admitted to Intensiva but we were the attending physicians for all of them. I was the medical director of Intensiva and split my time between the MICU and Intensiva – attending one month in the MICU and the next month in Intensiva. At the time, LTACHs were popping up all over the country, with several in Central Ohio. Our LTACH specialized in ventilator weaning so the largest group of patients we admitted were those with respiratory failure.
One day, we had a patient transferred from an ICU in Mansfield, Ohio. He had been in a motor vehicle accident and was not waking up from a coma. He also had respiratory failure and could not be weaned from a mechanical ventilator. So, the trauma surgeon in Mansfield performed a tracheostomy to keep him connected to a ventilator and performed a percutaneous gastrostomy feeding tube (PEG tube) to feed him.
In approaching a patient with failure to wean from the ventilator, the first step is to identify all of the contributions to respiratory failure. Some of the common reasons in a multiple trauma patient are pre-existing lung disease (like COPD), untreated infection, mucus plugging with atelectasis, paralyzed diaphragm, malnutrition, respiratory muscle deconditioning, fluid overload, electrolyte disturbances, anemia, and undiagnosed heart failure. So, my own routine approach to a new patient with respiratory failure was to start with a thorough history and physical exam and then order a chest x-ray, an EKG, an echocardiogram, a CBC (to check for anemia), a blood electrolyte panel, and a nutritional assessment.
This patient was a relatively young guy in his mid-30’s with no previous medical illnesses. His wife told me that he did not take any medications and seemed healthy prior to his accident. He had some soft tissue injury with bruises and contusions but no broken bones. He had sustained minor head trauma but a head CT had not shown any significant damage to his brain. But he was in a coma and just wouldn’t wake up.
As physicians, our best teachers are our patients – we learn the most from the patients that we encounter. Ever since my patient with catatonia from hypothyroidism more than a decade earlier, I had always held that every patient in a coma should have their thyroid tested once. So a TSH level was one of my routine admission lab tests for patients with coma or failure to wean from the ventilator. And my comatose trauma patient’s was 84 mIU/L. Intravenous thyroid hormone replacement is a bit tricky and requires a high level of monitoring so I was uncomfortable giving it outside of a regular intensive care unit. Therefore, we started him on a liquid form of the thyroid hormone replacement given through his feeding tube. Two days later, he was awake. Three days later, he was off of the mechanical ventilator. A week later, he was walking with the physical therapist and we removed his tracheostomy tube. A month after his admission to Intensiva, he was discharged home as a normal person. If his TSH level had not been checked, he likely would have spent the rest of his life in a skilled nursing facility, hooked up to a ventilator.
A weird gland
The thyroid is a weird gland. If it produces too much thyroid hormone, you get sick. If it produces too little thyroid hormone, you get sick. In either case, patients can present with a myriad of symptoms that frequently mimic other medical conditions. Hypothyroidism can be caused by many things – autoimmune conditions, inflammation, iodine deficiency, surgery, side effect of certain medications, radiation, and genetic conditions, just to name a few. In milder forms, hypothyroidism is a sneaky medical condition and can present with non-specific symptoms of fatigue, depression, weight gain, and memory loss. The good news is that it is easily treated, as long as the physician thinks about it and tests for it and as long as your grandmother doesn’t believe that the treatment is a potion created by Satan.
April 30, 2025
