Case of the Sweaty Salesman

Case of the Sweaty Salesman

This week’s subject revolves around the intriguing case of Michael, a 32 year old sales representative whose job keeps him on the move, meeting clients in his region for approximately four days each week. During a routine physical examination, he casually mentions to his physician an unusual issue—he appears to be sweating profusely, even in rooms that used to feel comfortable. This excessive sweating persists, even when he is at home, making rooms that are perfectly comfortable for his wife and children feel unbearably hot for him.

Shadow Health Respiratory Tina Jones Documentation Documentation / Electronic Health Record

Michael also reports unexpected weight loss, despite an increased appetite. He experiences a shortened attention span and an urge to be in constant motion. Fatigue plagues him, yet he struggles with sleep difficulties and more frequent bowel movements, occasionally accompanied by diarrhea. His physician, noticing a significant weight loss of 15 pounds since his last checkup, wants to rule out the possibility of HIV infection, so questions regarding his sexual history and practices are thoroughly explored, revealing no risk of HIV infection.

Furthermore, Michael’s medical history is devoid of chronic illnesses, he is a non-smoker, and his risk of cardiovascular disease is low. However, his family history unveils a different aspect—he has a positive family history of autoimmune diseases. His father has idiopathic thrombocytopenia, his mother is diagnosed with rheumatoid arthritis, and his oldest sister recently received a diagnosis of systemic lupus erythematosus.

During the physical examination, Michael displays signs of concern, including tachycardia, pronounced heart sounds, and an apparent cardiac arrhythmia accompanied by mild hypertension. An electrocardiogram confirms the arrhythmia’s supra-ventricular origin. Other notable physical characteristics include bulging eyeballs, fine and soft hair, and the beginnings of alopecia. Palmar erythema is also observed, along with the presence of a goiter upon neck palpation.

Blood tests reveal elevated levels of thyroid hormones (thyroxin and triiodothyronine), hypercalcemia, and reduced lipid concentrations. Based on these physical traits and blood test results, Michael’s physician suspects hyperthyroidism and refers him to an endocrinologist for further evaluation.

Following the consultation and examination by the endocrinologist, tests are ordered to confirm hyperthyroidism. The results show increased levels of thyroid hormones in the blood and the presence of thyroid-stimulating antibodies. These antibodies specifically stimulate the thyroid gland by binding to the thyroid-stimulating hormone receptor on the thyroid gland’s follicular cell plasma membrane. Based on these findings, the endocrinologist diagnoses Michael with Grave’s disease, a type of hyperthyroidism believed to be autoimmune in origin.

Michael is presented with various treatment options, including medications like propylthiouracil and methimazole to reduce thyroid hormone production, radio-isotopic destruction of the thyroid gland using 131I, and surgical removal of the thyroid gland. After careful consideration, Michael opts for surgery, taking into account potential radiation effects on gamete development.

Following successful surgery, Michael is prescribed synthetic thyroid hormone to ensure his body receives the necessary thyroid hormone levels. He is advised to return for a follow-up evaluation of thyroid hormone concentrations within two months and cautioned to monitor his calcium intake.

Now, addressing the questions related to this case:

1. Why would an imbalance in thyroid hormones have such a widespread effect on the body?

An imbalance in thyroid hormones can have a significant impact on the body because these hormones regulate metabolism, affecting almost every cell and tissue. When thyroid hormones are excessive, as in hyperthyroidism, it can lead to increased metabolism, resulting in symptoms such as weight loss, excessive sweating, and increased heart rate.

2. Why was goiter observed in Michael’s case?

Goiter, the enlargement of the thyroid gland, was observed in Michael’s case because his immune system produced thyroid-stimulating antibodies that stimulated the thyroid gland excessively. This led to the gland’s enlargement, resulting in a visible goiter.

3. Given that Michael and his wife may want to have more children, why was radio-isotopic destruction of the thyroid gland ruled out?

Radio-isotopic destruction of the thyroid gland using 131I was likely ruled out because of the potential risks associated with radiation exposure, especially to gametes (reproductive cells). Radiation could have adverse effects on sperm and egg cells, potentially affecting fertility and increasing the risk of birth defects in future offspring. Hence, surgical removal of the thyroid gland may have been considered a safer option for Michael.