Endgames Case Report

A woman with neck pain and shortness of breath

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6553 (Published 03 October 2012) Cite this as: BMJ 2012;345:e6553
  1. Ravi Parekh, academic foundation year 1 trainee, Central Middlesex Hospital12,
  2. Tina Beaconsfield, associate specialist radiologist 1,
  3. Wing May Kong, consultant physician in endocrinology and diabetes, honorary senior lecturer12
  1. 1North West London Hospitals NHS Trust, London NW10 7NS, UK
  2. 2Imperial College London, Faculty of Medicine, Imperial College, Charing Cross Campus, London
  1. Correspondence to: R Parekh r.parekh{at}imperial.ac.uk

An 86 year old white woman with a history of angina, hypertension, and recurrent urinary tract infections presented after two days of worsening shortness of breath but no cough or fever. The previous week she had been a patient in a rehabilitation ward after a two week admission with a urinary tract infection and acute confusion. Her regular drugs comprised bisoprolol, simvastatin, and lansoprazole.

On examination, her temperature was normal, her heart rate was 144 beats/min and irregular, her blood pressure was 132/76 mm Hg, and she was mildly tachypnoeic, with an oxygen saturation of 93% on air. Her jugular venous pressure was raised and she had bilateral crepitations on auscultation.

Palpation of the neck identified a tender diffusely enlarged thyroid gland with no discrete nodules. Other signs of thyroid disease, including eye signs, were absent. The rest of the examination was unremarkable.

Electrocardiography confirmed new atrial fibrillation, with a ventricular rate of 140 beats/min. Cardiomegaly and pulmonary oedema were seen on chest radiography.

Blood tests showed thyroid stimulating hormone (TSH) 0.02 mIU/L (reference range 0.35-4.94), free triiodothyronine (T3) 12.3 pmol/L (2.6-5.7; 1 pmol=65 pg/dL), and free thyroxine (T4) 57.6 pmol/L (9.0-19.0; 1 pmol=0.08 ng/dL).


  • 1 On the basis of the abnormal thyroid function tests, what is the differential diagnosis?

  • 2 What investigations should be performed to determine the cause of these abnormal thyroid function tests?

  • 3 How should this patient be treated?


1 On the basis of the abnormal thyroid function tests, what is the differential diagnosis?

Short answer

A suppressed TSH with raised T3 and T4 indicates primary hyperthyroidism, which can be caused by increased synthesis of hormones or inflammation of the thyroid gland. Important differential diagnoses include Graves’ disease, toxic multinodular goitre, toxic adenoma, thyroiditis, and excess thyroid hormone intake.

Long answer

The regulation of thyroid hormones involves the hypothalamic-pituitary-thyroid axis. Thyrotrophin releasing hormone secreted by the paraventricular nucleus of the hypothalamus acts on the anterior …

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