Intended for healthcare professionals

Endgames Case Review

A 56 year old woman with syncope, weakness, and refractory hypotension

BMJ 2015; 350 doi: (Published 25 June 2015) Cite this as: BMJ 2015;350:h3387
  1. Amaya George, internal medicine physician1,
  2. Michael Phillips, cardiology fellow2,
  3. Lori Sweeney, endocrinologist3,
  4. Christopher Colombo, intensivist4
  1. 1Department of Internal Medicine, Dwight D Eisenhower Army Medical Center, Fort Gordon, GA, USA
  2. 2Department of Cardiology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
  3. 3Department of Endocrinology, Virginia Commonwealth University Health System, Richmond, VA, USA
  4. 4Department of Critical Care, Dwight D Eisenhower Army Medical Center
  1. Correspondence to: A George{at}

A 56 year old woman with hypothyroidism after total thyroidectomy presented to the emergency department after an episode of near syncope. When she arrived she had hypotension and atrial fibrillation, with a rapid ventricular response. She reported a history of progressive weakness, weight loss, polyuria, polydipsia, anorexia, and fatigue. Urine analysis was positive for leucocyte esterase and pyuria. She was admitted to the intensive care unit with a diagnosis of severe sepsis of urinary source and atrial fibrillation with a rapid ventricular response. After aggressive fluid resuscitation and the administration of intravenous antibiotics, her heart spontaneously converted to a normal rhythm and she appeared well perfused but remained hypotensive. Review of her medical record showed that her therapeutic thyroxine replacement had recently been decreased because of low thyrotrophin. On perusal of her records from an another facility it was noted that she had undergone pituitary mass resection and irradiation 20 years earlier.

After empirical treatment with thyroid hormone and glucocorticoids her hypotension resolved. On hospital day four she demonstrated haemodynamic stability and was transferred to the ward. On hospital day five she manifested dilute polyuria (urine osmolality of …

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