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Unexplained Weight Loss: A Case of Apathetic Hyperthyroidism

Unexplained Weight Loss: A Case of Apathetic Hyperthyroidism. Grand Rounds Livingston HealthCare. Julie Silverman, MD March 21, 2012. Disclosures. I have no disclosures. Outline. Case presentation Unintended Weight Loss in the Elderly Review of thyroid physiology

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Unexplained Weight Loss: A Case of Apathetic Hyperthyroidism

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  1. Unexplained Weight Loss: A Case of Apathetic Hyperthyroidism Grand RoundsLivingston HealthCare Julie Silverman, MD March 21, 2012

  2. Disclosures I have no disclosures.

  3. Outline • Case presentation • Unintended Weight Loss in the Elderly • Review of thyroid physiology • Apathetic Hyperthyroidism

  4. Chief Complaint • 80 y.o. man presenting to the ED s/p fall complaining of R leg pain

  5. Chief Complaint • 80 y.o. man presenting to the ED s/p fall complaining of R leg pain • 80 y.o. man complaining of 60lb weight loss

  6. History of Present Illness • 40-60 lb weight loss over prev 4-5 months • CVA 3 months ago • spent 5 wks in inpatient rehab followed by 2 mos at subacute rehab • PEG placed on d/c from hospital d/t swallowing difficulties; removed when left inpatient rehab • residual deficits: aphasia, confusion, R-sided weakness • Decreased PO intake • ? odynophagia or dysphagia • ? Δ appetite

  7. Pertinent Negatives • No fevers, chills or night sweats • No Δ in bowel habits (diarrhea, constipation, Δ stool color) • No nausea/vomiting • No abdominal pain • No chest pain, palpitations, SOB • No Δ in physical activity level • No Δ in sleep habits

  8. Past Medical and Surgical Hx • CVA (2 months ago) • PEG placement and removal • CAD • DM Type 2 • HTN • Paroxysmal a-fib (remote past) • Prostate CA 1993 s/p resection, chemo and radiation therapy • Appendectomy • Polio (age 12) L arm weakness

  9. Remainder of History Meds: Social: • Metformin 1000mg BID • Metoprolol 25mg BID • Simvastatin 20mg QHS • MVI • Warfarin • ASA • Glimepiride • Glyburide • Plavix • Amiodarone • Casodex • Lives with wife • Metropolitan YMCA VP, retired • 1-2 drinks/wk prior to stroke • No tobacco use • No illicit drug use Family Hx: • 3 siblings with DM • Mother ? heart problem

  10. Differential Dx

  11. Differential Dx Malignancies Visceral GI Lymphomas

  12. Differential Dx Malignancies Visceral GI Lymphomas Non-malignant GI disorders Advanced liver disease Celiac disease Chronic pancreatitis Crohn’s Gastroparesis Malabsorption NOS Peptic ulcer disease Swallowing dysfunction

  13. Differential Dx Malignancies Visceral GI Lymphomas Non-malignant GI disorders Advanced liver disease Celiac disease Chronic pancreatitis Crohn’s Gastroparesis Malabsorption NOS Peptic ulcer disease Swallowing dysfunction Endocrinopathies Adrenal insufficiency Diabetes mellitus Hypercalemia Hyperthryoidism Panhypopituitarism Pheochromocytoma

  14. Differential Dx Malignancies Visceral GI Lymphomas Other Illnesses Advanced COPD Advanced CHF Advanced renal disease Smoldering infections HIV SBE Tuberculosis Vasculitis Non-malignant GI disorders Advanced liver disease Celiac disease Chronic pancreatitis Crohn’s Gastroparesis Malabsorption NOS Peptic ulcer disease Swallowing dysfunction Endocrinopathies Adrenal insufficiency Diabetes mellitus Hypercalemia Hyperthryoidism Panhypopituitarism Pheochromocytoma

  15. Differential Dx Malignancies Visceral GI Lymphomas Other Illnesses Advanced COPD Advanced CHF Advanced renal disease Smoldering infections HIV SBE Tuberculosis Vasculitis Non-malignant GI disorders Advanced liver disease Celiac disease Chronic pancreatitis Crohn’s Gastroparesis Malabsorption NOS Peptic ulcer disease Swallowing dysfunction Medications/Drugs Alcohol Amphetamines Cocaine Digoxin Levodopa Metformin NSAIDs Opiates SSRIs Endocrinopathies Adrenal insufficiency Diabetes mellitus Hypercalemia Hyperthryoidism Panhypopituitarism Pheochromocytoma

  16. Differential Dx Malignancies Visceral GI Lymphomas Other Illnesses Advanced COPD Advanced CHF Advanced renal disease Smoldering infections HIV SBE Tuberculosis Vasculitis Psychiatric Bipolar disorder Dementia Depression Dysmorphic syndromes Paranoid delusional states Personality disorders Non-malignant GI disorders Advanced liver disease Celiac disease Chronic pancreatitis Crohn’s Gastroparesis Malabsorption NOS Peptic ulcer disease Swallowing dysfunction Medications/Drugs Alcohol Amphetamines Cocaine Digoxin Levodopa Metformin NSAIDs Opiates SSRIs Endocrinopathies Adrenal insufficiency Diabetes mellitus Hypercalemia Hyperthryoidism Panhypopituitarism Pheochromocytoma

  17. Differential Dx Malignancies Visceral GI Lymphomas Other Illnesses Advanced COPD Advanced CHF Advanced renal disease Smoldering infections HIV SBE Tuberculosis Vasculitis Psychiatric Bipolar disorder Dementia Depression Dysmorphic syndromes Paranoid delusional states Personality disorders Non-malignant GI disorders Advanced liver disease Celiac disease Chronic pancreatitis Crohn’s Gastroparesis Malabsorption NOS Peptic ulcer disease Swallowing dysfunction Psychosocial/Functional Inability to shop/prepare food Loss of teeth, poor denture fit Marked increase physical activity Poverty Social isolation Medications/Drugs Alcohol Amphetamines Cocaine Digoxin Levodopa Metformin NSAIDs Opiates SSRIs Endocrinopathies Adrenal insufficiency Diabetes mellitus Hypercalemia Hyperthryoidism Panhypopituitarism Pheochromocytoma Mayo Clinic Proceedings 76(9), September 2001, pp 923-929

  18. Unintentional Weight Loss in the Elderly • Weight loss is associated with increased mortality or morbidity or both • 15-20% prevalence, though estimates vary widely; no gender difference • Similar causes as non-elderly but additional factors • Person with dementia or late-life psychotic d/o may be paranoid and suspicious that food being poisoned • Person with dementia and habitual wandering may expend significant energy in pacing • Physiologic changes in elderly  early satiety and anorexia • Decline in taste and smell • Reduced efficiency of chewing • Slowed gastric emptying • Alternations in neuroendocrine axis CMAJ • MAR. 15, 2005; 172 (6)

  19. Unintentional Weight Loss in the Elderly CMAJ • MAR. 15, 2005; 172 (6)

  20. Physical Exam

  21. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63

  22. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor

  23. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape

  24. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy

  25. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy • CV: Tachycardic, irregular rhythm, S1, S2, no murmurs/rubs/gallops

  26. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy • CV: Tachycardic, irregular rhythm, S1, S2, no murmurs/rubs/gallops • Resp: CTAB, no wheezing, rales, ronchi

  27. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy • CV: Tachycardic, irregular rhythm, S1, S2, no murmurs/rubs/gallops • Resp: CTAB, no wheezing, rales, ronchi • GI: +BS, S/NT/ND, no hepatomegaly

  28. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy • CV: Tachycardic, irregular rhythm, S1, S2, no murmurs/rubs/gallops • Resp: CTAB, no wheezing, rales, ronchi • GI: +BS, S/NT/ND, no hepatomegaly • Ext: R foot bandaged to knee, no edema L leg

  29. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy • CV: Tachycardic, irregular rhythm, S1, S2, no murmurs/rubs/gallops • Resp: CTAB, no wheezing, rales, ronchi • GI: +BS, S/NT/ND, no hepatomegaly • Ext: R foot bandaged to knee, no edema L leg • Neuro: CN II-XII grossly intact, AAOx1 (to self), strength 5/5 left leg & 3/5 B arms, aphasia, B resting tremor (did not improve with intention), DTR 2+

  30. Physical Exam • Temp 36.2, HR 117, RR 20, BP121/63 • Gen: well-appearing, NAD, B resting tremor • HEENT: PERRLA, EOMI, arcus senilis, brown spots on sclerae, anicteric, pink conjunctivae, nl dentition, oropharynx MMM, thyroid nl size/shape • LAD: No lymphadenopathy • CV: Tachycardic, irregular rhythm, S1, S2, no murmurs/rubs/gallops • Resp: CTAB, no wheezing, rales, ronchi • GI: +BS, S/NT/ND, no hepatomegaly • Ext: R foot bandaged to knee, no edema L leg • Neuro: CN II-XII grossly intact, AAOx1 (to self), strength 5/5 left leg & 3/5 B arms, aphasia, B resting tremor (did not improve with intention), DTR 2+ • Skin: no evidence of sacral skin breakdown

  31. Labs & Tests

  32. Labs & Tests 10.2 8.3 142 107 22 1.5 5.9 5.9 192 152 4.2 27 1.1 3.2 MCV 83 MCH 27.2 MCHC 32.8 RDW 13.0 EKG: Normal sinus rhythm with freq PACs

  33. Labs & Tests 10.2 8.3 142 107 22 1.5 5.9 5.9 192 152 4.2 27 1.1 3.2 MCV 83 MCH 27.2 MCHC 32.8 RDW 13.0 Iron 18 (40-160) Ferritin 374 (20-300) TIBC 173 (230-430) VitB12 743 (240-900) Folate 15.1 (4.0-19.9) FOBT neg UA neg for blood EKG: Normal sinus rhythm with freq PACs

  34. Labs & Tests 10.2 8.3 142 107 22 1.5 5.9 5.9 192 152 4.2 27 1.1 3.2 MCV 83 MCH 27.2 MCHC 32.8 RDW 13.0 Iron 18 (40-160) Ferritin 374 (20-300) TIBC 173 (230-430) VitB12 743 (240-900) Folate 15.1 (4.0-19.9) FOBT neg UA neg for blood EKG: Normal sinus rhythm with freq PACs Chol 78 (120-199) HDL 43 (40-80) LDL 25 (60-129) TGs 52 (30-149) HbA1C 6.6

  35. Labs & Tests 10.2 8.3 142 107 22 1.5 5.9 5.9 192 152 4.2 27 1.1 3.2 MCV 83 MCH 27.2 MCHC 32.8 RDW 13.0 Iron 18 (40-160) Ferritin 374 (20-300) TIBC 173 (230-430) VitB12 743 (240-900) Folate 15.1 (4.0-19.9) FOBT neg UA neg for blood EKG: Normal sinus rhythm with freq PACs Chol 78 (120-199) HDL 43 (40-80) LDL 25 (60-129) TGs 52 (30-149) HbA1C 6.6 TSH 0.01 (0.3-3.8) T3 132 (80-195) T4 18.1 (5.0-11.6) FT4 34 (6-10.5)

  36. Labs & Tests 10.2 8.3 142 107 22 1.5 5.9 5.9 192 152 4.2 27 1.1 3.2 MCV 83 MCH 27.2 MCHC 32.8 RDW 13.0 Iron 18 (40-160) Ferritin 374 (20-300) TIBC 173 (230-430) VitB12 743 (240-900) Folate 15.1 (4.0-19.9) FOBT neg UA neg for blood EKG: Normal sinus rhythm with freq PACs Chol 78 (120-199) HDL 43 (40-80) LDL 25 (60-129) TGs 52 (30-149) HbA1C 6.6 TSH 0.01 (0.3-3.8) T3 132 (80-195) T4 18.1 (5.0-11.6) FT4 34 (6-10.5)

  37. Thyroid Basics • The thyroid gland synthesizes, stores, & secretes the thyroid hormones (T4 and T3) Approximately 99.98% of T4 and 99.7% of T3 are bound to proteins (thyroxine-binding globulin, transthyretin and albumin)

  38. Thyroid Basics • The thyroid gland synthesizes, stores, & secretes the thyroid hormones (T4 and T3) • Approximately 99.98% of T4 and 99.7% of T3 are bound to proteins (thyroxine-binding globulin, transthyretin and albumin)

  39. Thyroid Basics TRH = Thyroid Releasing Hormone TSH = Thyroid Stimulating Hormone = Thyrotropin T4 = Thyroxine T3 = Triiodothyronine

  40. Thyroid Basics TSH normal = no dysfunction TRH = Thyroid Releasing Hormone TSH = Thyroid Stimulating Hormone = Thyrotropin T4 = Thyroxine T3 = Triiodothyronine

  41. Thyroid Basics TSH normal = no dysfunction ↓ TSH = hyperthyroidism TRH = Thyroid Releasing Hormone TSH = Thyroid Stimulating Hormone = Thyrotropin T4 = Thyroxine T3 = Triiodothyronine

  42. Thyroid Basics TSH normal = no dysfunction ↓ TSH = hyperthyroidism ↑ TSH = hypothyroidism TRH = Thyroid Releasing Hormone TSH = Thyroid Stimulating Hormone = Thyrotropin T4 = Thyroxine T3 = Triiodothyronine

  43. Thyroid Basics TSH normal = no dysfunction ↓ TSH = hyperthyroidism ↑ TSH = hypothyroidism To confirm diagnosis, check free T4 and free T3 levels TRH = Thyroid Releasing Hormone TSH = Thyroid Stimulating Hormone = Thyrotropin T4 = Thyroxine T3 = Triiodothyronine

  44. Thyrotoxicosis/Hyperthyroidism • Hypermetabolic clinical syndrome resulting from serum elevations in thyroid hormone levels • Hyperthyroidism = a type of thyrotoxicosis in which accelerated thyroid hormone biosynthesis and secretion by the thyroid gland produce thyrotoxicosis Endocrinol Metab Clin North Am. 2007 Sep;36(3):617-56, v. Review.

  45. Manifestations of Thyrotoxicosis

  46. Hyperthyroidism in the Elderly(a.k.a. Apathetic Hyperthyroidism) Ann Intern Med May 1, 1970 72:679-685

  47. Hyperthyroidism in the Elderly Comparison between young and old patients with symptoms and signs of hyperthyroidism Differences in the Signs and Symptoms of Hyperthyroidism in Older and Younger Patients Journal of the American Geriatrics Society - Volume 44, Issue 1 (January 1996)

  48. Hyperthyroidism in the Elderly Comparison between old patients with hyperthyroidism and old controls ` `

  49. “The following seem to be the salient clinical characteristics of apathetic thyrotoxicosis: • An elderly patient with a fairly typical placid apathetic facies, quite different from the usual hyperkinetic thyrotoxic patient • A smaller goiter • The presence of depression, lethargy, or apathy • Absence of ocular manifestations usually associated with hyperthyroidism • Substantial muscular weakness and wasting • Excessive weight loss; and • Cardiovascular dysfunction with atrial fibrillation. The patient may present with the complete syndrome of apathetic thyrotoxicosis or may present any of a spectrum of findings, the most important of which is the central nervous system ‘nonactivation.’” Ann Intern Med May 1, 1970 72:679-685

  50. Back to My Patient… TSH 0.01 (0.3-3.8) T3 132 (80-195) T4 18.1 (5.0-11.6) FT4 34 (6-10.5)

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