Rayid Abdulqawi

Hyperthyroidism presenting with persistent vomiting, headache and deranged liver function tests

A 58-year-old lady with no significant past medical history was admitted with a 3-week history of severe headache and persistent vomiting. Physical examination was unremarkable. Initial investigations including full blood count, renal function, C-reactive protein and chest X-ray were unremarkable. CT scan of the head and cerebrospinal fluid (CSF) pressure and analysis were normal. She was treated symptomatically and discharged home 8 days post admission. Two weeks later, the patient was re-admitted with the same symptoms. She reported a weight loss of 2 stones. Physical examination was unremarkable, except for sinus tachycardia of 134 bpm. Her liver function tests were abnormal: ALP 109 IU/L (45–120), ALT 207 IU/L (10–37), bilirubin 41 mmol/L (0–17) and GGT 139 IU/L (0–75). Autoimmune and viral hepatitis screen was normal. Ultrasound (U/S) of the abdomen showed no abnormalities. Upper gastrointestinal endoscopy revealed reflux esophagitis secondary to the vomiting. Barium meal and small bowel studies were negative. She was treated with omeprazole, anti-emetics and analgesia with no improvement. While shewas in the hospital, the patientwas noted to have a heat intolerance which, in combination with weight loss and tachycardia, led us to consider hyperthyroidism. Thyroid function tests confirmed the diagnosis of hyperthyroidism [TSH b0.05 mU/l (0.4–4), FT4 68.8 pmol/l (10–25)].Thyroid U/S scan revealed a small multinodular goitre. On treatment with carbimazole and propranolol, her symptoms resolved completely within 4 days (after 5 weeks of persistent vomiting and headache). At 6-week follow-up at the outpatient clinic, she was asymptomatic and biochemically euthyroid on carbimazole 20 mg/day with normalisation of her liver function tests. The majority of patients with hyperthyroidism are readily diagnosed clinically. Unusual initial presenting features may lead to a delay in the diagnosis. Severe headache, persistent vomiting and abnormal liver function are rare, but recognized, presenting manifestations of hyperthyroidism [1,2]. This case highlights the need to exclude hyperthyroidism in patients with unexplained persistent vomiting, headache and deranged liver function tests. Awareness of these atypical presentations will assist physicians in making a timely and cost-effective diagnosis.