QJM Advance Access originally published online on September 3, 2008
QJM 2008 101(11):871-874; doi:10.1093/qjmed/hcn107
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Newly diagnosed thyrotoxicosis in hospitalized patients: clinical characteristics
From the 1Department of Medicine E, 2Department of Diagnostic Imaging and 3Endocrine Unit, Meir Medical Center, Kfar-Saba, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Address correspondence to Dr P. Rotman-Pikielny, Department of Medicine E, Meir Medical Center, 59 Tshernihovsky St, Kfar-Saba 95847, Israel. email: pnina.rotman{at}clalit.org.il
Received 15 March 2008 and in revised form 8 August 2008
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Summary |
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Background: Thyrotoxicosis is often diagnosed in an outpatient setting. The most common symptoms include irritability, heat intolerance, palpitations and weakness. Sometimes, however, thyrotoxicosis is first diagnosed in the hospital setting. The prevalent symptoms in hospitalized patients with newly diagnosed thyrotoxicosis have not been fully characterized.
Aim: To determine the clinical characteristics of patients with thyrotoxicosis newly diagnosed during hospitalization.
Design: A retrospective computer-based search was undertaken to detect patients that were hospitalized in our medical centre during 1999–2006, and discharged with thyrotoxicosis or thyroiditis as the primary diagnosis.
Results: Fifty-eight patients (36F/22M; mean age 52.1 ± 17.5 years) were identified. Weakness, weight loss and palpitations were the most common manifestations (50, 40 and 35%, respectively) and were predominantly present in patients with hyperthyroidism. Sore throat was present in 41% of patients with thyroiditis. Sinus tachycardia and atrial fibrillation occurred in 65.5 and 15.5% of the patients, more common in those with hyperthyroidism. The diagnoses on discharge were Graves’ disease, subacute thyroiditis and multinodular goiter in 39.7, 34.5 and 8.9%, respectively.
Conclusions: Weakness, weight loss and palpitations were the main symptoms in patients diagnosed with thyrotoxicosis during hospitalization. Thyrotoxicosis should be included in the differential diagnosis when patients are admitted to the hospital with those symptoms.
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Background |
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Thyrotoxicosis denotes a set of symptoms and signs related to elevated serum thyroid hormone concentration. The most common symptoms include irritability, increased sweating, heat intolerance, palpitations and weakness.1–4 Most of the patients with thyrotoxicosis are diagnosed as outpatients, yet, some are first diagnosed during hospitalization. The prevalent symptoms in such patients have been scarcely described before.5–8
Objective
To determine the clinical characteristics of newly diagnosed thyrotoxicosis during hospitalization and to investigate them according to the common etiologies, mainly Graves’ disease (GD) and thyroiditis.
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Design |
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This retrospective study was performed at a secondary referral hospital, an 800 bed, university affiliated medical centre. A computer-based search of all the patients hospitalized between 1 January 1999 and 31 December 2006 identified patients that were discharged with thyrotoxicosis or thyroiditis as a primary diagnosis.
Inclusion criteria included: (i) age 
18 years, (ii) nonpregnant adults, (iii) the diagnosis of thyrotoxicosis was newly made during hospitalization and (iv) laboratory findings were consistent with overt thyrotoxicosis, i.e. suppressed thyrotropin (TSH) level and elevated free thyroxine (FT4) or elevated total triiodothyronine level (TT3). Patients with a known thyroid disorder, on thyroid-specific medications (L-thyroxine or thionamids) or with subclinical thyrotoxicosis (suppressed TSH level with normal FT4 and TT3) were excluded.
Demographic and clinical data were retrospectively reviewed according to the discharge summary or an outpatient report.
Serum TSH level determinations were performed using a continuous random access analyzer (Immulite, Diagnostic products Corp, Los Angeles, CA, USA) with normal levels of 0.23–4 mU/l. FT4 and TT3 level determinations were performed as described, with normal levels of 0.8–2.0 ng/dl and 80–180 ng/dl, respectively.9
This study was approved by the ethical committee of the medical centre.
Statistical analysis
Continuous parameters are expressed as mean ± SD and percentage in parenthesis and categorical parameters are expressed as percentages. Comparisons between the two groups of patients (hyperthyroidism vs. thyroiditis) regarding demographic (gender, age) and clinical (signs, symptoms) parameters were done by the Chi-square, Fisher's exact tests and unpaired t-test, as applicable.
The statistical significance was 0.05. The statistical analyses were performed using the SPSS for Windows software, version 14.0 (Copyright SPSS Inc., IL, USA).
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One hundred and eighty-five patients had a primary diagnosis of thyrotoxicosis or thyroiditis during the study period (7 years). Fifty-eight of them were newly diagnosed during hospitalization, comprising 0.25 ± 0.012% of all hospital admissions.
The main demographic, clinical and laboratory data of our series are summarized in Tables 1
and 2. Most of the patients were hospitalized in the internal medicine department (93%) and a minority in the geriatric, neurology and ear, nose and throat departments (3.4, 1.7 and 1.7%, respectively). Ninety-one percent of the patients presented with multiple symptoms. Age correlated negatively with the number of symptoms (r = –0.342 P = 0.009), while gender was not related to the number or type of symptoms (data not shown).
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Symptoms and signs were described in the entire cohort and in two main subgroups; patients with hyperthyroidism [GD, toxic multinodular goiter and toxic adenoma (N = 30)] and patients with thyroiditis [subacute, amiodarone-induced and silent thyroiditis (N = 28)] (Figure 1A and B). Weakness and weight loss were the most common manifestations (50 and 39.6%, respectively), followed by palpitations (34.5%). Interestingly, the classic symptoms of tremor and heat intolerance were reported by 10 and 3.4% of the patients only and nervousness only by one patient. On physical examination, atrial fibrillation was present in 15.5%, goiter was reported in 66.7% of the patients with hyperthyroidism and in 40.7% of the patients with thyroiditis. Regarding the hormonal findings, TT3 was elevated in 75.9% of the entire cohort, being elevated in 80% of the patients with thyroiditis. T3 thyrotoxicosis (elevated serum level of TT3 with normal FT4) was documented in 3 of our 58 patients (5.2%). Overall, technecium thyroid scan was performed in 49 of all the patients (84.5%), in 44 of them during hospitalization. The diagnoses on discharge were GD and subacute thyroiditis (SAT) in 40 and 34.5%, respectively, followed by toxic multinodular goiter and amiodarone-induced thyroiditis in 8.6 and 6.9%, respectively.
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Conclusions |
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The etiology and the clinical manifestations of thyrotoxicosis newly diagnosed during hospitalization have rarely been reported.5–8
The results of this study indicate that the most common presenting symptoms in the hospital setting were weakness or fatigue, weight loss and palpitations. Nervousness and heat intolerance, that were previously reported as the commonest thyrotoxic symptoms,1,2 were infrequently reported by our patients. A high frequency of various thyrotoxic symptoms; palpitations, tremor and weight loss (82% each) was recently reported in younger, <35 years, patients with thyrotoxicosis.8 We can assume that in an outpatient endocrine clinic these complaints are more carefully addressed than on admission to an internal medicine department.
Weight loss might be the only presenting symptom of thyrotoxicosis in older patients.7,10 In our series, it was a major presenting symptom found in 40% of the entire group. Anorexia, previously reported in a third of elderly thyrotoxic patients could contribute to weight loss.7 Yet, anorexia was not specifically mentioned by our patients. Atrial fibrillation was present within the previously reported rate of 
10–20% in thyrotoxic patients.1,5
Younger patients with thyrotoxicosis tend to have more symptoms in comparison with older patients with similar thyroid function tests.3 Our patients, relatively young, (mean age of 52 years) did present with multiple symptoms, with an average of three symptoms per person. They also had fewer co-morbidities (1.2 per patient) in comparison to the typical population in internal medicine departments.11
TT3 was elevated in 75.9% of the entire cohort, in agreement with previous reports and even more often in the patients with thyroiditis, which usually present with preferential T4 toxicosis.12 T3 thyrotoxicosis was infrequently documented in our patients, similarly to previous reports.13
Regarding the diagnosis, GD was detected in 40% of our patients and SAT in 34.5%. On the contrary, GD accounts for 50–70% of ambulatory patients with thyrotoxicosis while SAT is reported only in 5%.8,14 The high incidence of SAT in our study may be explained by the fact that the diagnosis of GD is usually straightforward being established mostly on ambulatory basis, while the diagnosis of SAT may be more difficult, leading to hospitalization.
Our study focuses on the clinical manifestations of patients with thyrotoxicosis in an inpatient setting, found to have an incidence of 0.25% of all adult hospital admissions. This data may even underestimate the real incidence of thyrotoxicosis in hospitalized patients, since results of the thyroid function tests might have not been available during discharge. Unfortunately, we do not have an estimation of the accuracy of our coding system and, hence, imperfect coding system might have led to few undetected cases.
The limitation of our study is its retrospective nature, totally based upon the information found in the charts. In addition, since thyroid pathology was not diagnosed prior to the hospital admission, classic thyroid-related symptoms might not have been addressed. Additionally, since our study did not have a comparator group, there is an uncertainty regarding the presence of nonspecific symptoms like weakness and weight loss in other acutely ill inpatients. Prospective studies of the incidence, etiology and clinical presentation of thyrotoxicosis in hospitalized patients are recommended.
To conclude, weakness, weight loss and palpitations were the leading symptoms in patients newly diagnosed with thyrotoxicosis during hospitalization. Thyrotoxicosis should, therefore, be included in the differential diagnosis of patients presenting with those symptoms in the hospital setting.
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This work was presented in part in the 78th annual meeting of the American Thyroid Association meeting, New York, October 2007.
Conflict of interest: None declared.
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References |
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1. Davies TF, Larsen PR. Thyrotoxicosis. In: Williams Textbook of Endocrinology.—Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, eds. (2002) 10th edn. Philadelphia: WB Saunders Company. 374–421.
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14. Johannesson AJ, Gudmundsdottir A, Hreidarsson A, Sigurdsson G, Thorsson N, Bjarnason R, et al. Incidence, classification and clinical features of thyrotoxicosis in Iceland. Thyroid (2007) 17:S-126.
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