Abstract
A 62 year man with tablet-controlled type 2 diabetes was referred by his general practitioner to the emergency medical unit with shortness of breath. He was found to be in atrial fibrillation with a heart rate of 130 beats/min and the patient was commenced on sotalol and warfarin. Thyroid function tests were requested and found to be abnormal, with thyroid-stimulating hormone (TSH) 7.75 mU/l (reference range 0.35–4.5), raised serum thyroxine (FT4) 49.3 pmol/l (11–24) and triiodothyronine (FT3) 10.3 pmol/l (3.9–6.8). On re-examination, the patient did not have a goitre or any clinical features of hyperthyroidism other than atrial fibrillation. A differential diagnosis of assay interference, a TSH secreting pituitary adenoma or thyroid hormone resistance was considered. Samples were sent for repeated analysis in a second laboratory to look for evidence of assay interference; these confirmed a raised TSH with a raised FT3 and FT4. Thyroid antibodies, a thyrotrophin-releasing hormone (TRH) test and pituitary magnetic resonance imaging (MRI) were organized for the patient on an outpatient basis. The patient was discharged from hospital to be followed up by the Endocrine team. Ten days after discharge, the patient re-presented to the emergency medical unit with headaches, vomiting and slurred speech. Neurological examination revealed dysarthria, horizontal nystagmus, left-sided dysdiadokinesis and past-pointing, reduced …
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