PMC9246615_01
Imaging findings at first admission. (a) Chest X-ray on admission and discharge. (b) An ultrasonogram showing enlargement and increased blood flow of the thyroid gland.
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A chest radiograph and electrocardiogram showed cardiac dilation, bilateral pleural effusion, and a rapid atrial fibrillation (AF) rhythm (Figures 1(a) and 2). TSH level (<0.01 muU/mL) and elevated free T3 (16.4 pg/mL) and free T4 levels (>7.7 ng/dL), and the patient was referred for hyperthyroidism. Thyrotropin receptor antibody (TRAb) measured using the electrochemiluminescence assay method was 24.7 (normal range, <2.0) IU/L, and goiter with increased blood flow was confirmed by ultrasonography (Figure 1(b)).
Electrocardiogram (ECG) findings at first admission. (a) Rapid atrial fibrillation on admission, atrial tachycardia on day 5, and normal sinus rhythm on discharge. (b) ECG monitor display showing ventricular tachycardia on day 3.
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After admission, sustained VT occurred, so an electrical cardioversion was performed and intravenous amiodarone was administered (Figure 2). Moreover, atrial tachycardia, for which both 50 mg intravenous lidocaine and 20 milliequivalent magnesium sulfate were ineffective, occurred and required electrical cardioversion again, and 1 mug/kg/min intravenous landiolol was initiated (Figure 2). After initial treatment of the TS, lethal arrhythmia including VT did not reoccur, and he returned to a normal sinus rhythm several days later (Figure 2). As thyroid function gradually decreased, intravenous hydrocortisone was tapered off and altered to oral prednisolone (PSL), and KI was decreased to 100 mg/day.
Total clinical course of the patient. Open circles indicate the value of free T4 mean more than 7.7 ng/dL. HCZ: hydrocortisone; PSL: prednisolone; MMI: methimazole; KI: potassium iodide; VT: ventricular tachycardia; T3: triiodothyronine; and T4: thyroxine.
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The thyroid function test results 6 days after the initiation of TS therapy were as follows: free T3 = 3.4 pg/mL and free T4 = 3.7 ng/dL (Figure 3). The free T4 level remained high, but the free T3 level returned to normal. The total clinical course of the patient is shown in Figure 3.
Clinical course of the patient during the second admission due to febrile neutropenia. G-CSF: granulocyte colony-stimulating factor; MEPM: meropenem; AMPC: amoxicillin; CVA: clavulanate; LVFX: levofloxacin; and BT: body temperature.
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The clinical course of second admission is shown in Figure 4.