A delayed diagnosis of hyperthyroidism in a patient with persistent vomiting in the presence of Chiari type 1 malformation
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Diana Rodriguez-Hurtado
,
José Camones-Huerta
and
Claudia Núñez Mochizaki
Abstract
Objectives
To present and discuss an uncommon clinical presentation of hyperthyroidism in a female patient with Chiari type 1 malformation. We explore how her medical history influenced the diagnostic process and ultimately contributed to the delayed diagnosis.
Case presentation
In this case study, we discuss an unusual presentation of hyperthyroidism in a 35-year-old female with Chiari type 1 malformation. Initially experiencing headaches, tremors, and dizziness, the patient consulted multiple specialists without a clear diagnosis. Later, she developed recurrent vomiting unrelated to food intake, significant weight loss (12 kg), and muscle weakness, leading to her hospitalization. After six months of clinical evaluation with several specialists (neurologists, neurosurgeons, and gastroenterologists), she was, finally, diagnosed with hyperthyroidism by an Internal Medicine physician in another private clinic. Treatment with thiamazole and propranolol led to the improvement of symptoms progressively. This case emphasizes the vital role of clinical reasoning, crucial problem-solving, and decision-making processes while addressing cognitive biases in medical specialization. Besides, it highlights the need for internist evaluation in outpatient care to ensure comprehensive assessment and prompt specialist referrals if needed.
Conclusions
This case accentuates the importance of internist evaluation for comprehensive care and timely specialist referrals. Recognizing unusual presentations, like thyrotoxic vomiting, and addressing cognitive biases, such as confirmation and anchor biases, are crucial for accurate and prompt diagnosis. This approach enhances diagnostic accuracy, minimizing unnecessary tests and costs, and alleviates patient suffering.
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Research ethics: Not applicable.
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Informed consent: Informed consent was obtained from all individuals included in this study, or their legal guardians or wards.
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Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: The authors state no conflict of interest.
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Research funding: None declared.
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Data availability: Not applicable.
References
1. Zisakis, A, Sun, R, Pepper, J, Tsermoulas, G. Chiari malformation type 1 in adults. Adv Tech Stand Neurosurg 2023;46:149–73. https://doi.org/10.1007/978-3-031-28202-7_8.Search in Google Scholar PubMed
2. Kular, S, Cascella, M. Chiari I malformation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. [cited 2023 Oct 2]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK554609/.Search in Google Scholar
3. Connelly, DP, Johnson, PE. The medical problem solving process. Hum Pathol 1980;11:412–9. https://doi.org/10.1016/s0046-8177(80)80048-7.Search in Google Scholar PubMed
4. Gharahbaghian, L, Brosnan, DP, Fox, JC, Stratton, SJ, Langdorf, MI. New onset thyrotoxicosis presenting as vomiting, abdominal pain and transaminitis in the emergency department. West J Emerg Med 2007;8:97–100.Search in Google Scholar
5. Shim, S, Ryu, HS, Oh, HJ, Kim, YS. Thyrotoxic vomiting: a case report and possible mechanisms. J Neurogastroenterol Motil 2010;16:428–32. https://doi.org/10.5056/jnm.2010.16.4.428.Search in Google Scholar PubMed PubMed Central
6. Müller-Michaels, J, Bürk, G, Andler, W. Vomiting as main symptom: unusual presentation of a hyperthyroidism in a 12-year-old boy. Klin Pädiatr 1997;209:141–3. https://doi.org/10.1055/s-2008-1043945.Search in Google Scholar PubMed
7. Hoogendoorn, EH, Cools, BM. Hyperthyroidism as a cause of persistent vomiting. Neth J Med 2004;62:293–6.Search in Google Scholar
8. Bilezikian, JP, Loeb, JN. The influence of hyperthyroidism and hypothyroidism on alpha- and beta-adrenergic receptor systems and adrenergic responsiveness. Endocr Rev 1983;4:378–88. https://doi.org/10.1210/edrv-4-4-378.Search in Google Scholar PubMed
9. Farshbaf-Khalili, A, Salehi-Pourmehr, H, Najafipour, F, Alamdari, NM, Pourzeinali, S, Ainehchi, N. Is hyperemesis gravidarum associated with transient hyperthyroidism? A systematic review and meta-analysis. Taiwan J Obstet Gynecol 2023;62:205–25. https://doi.org/10.1016/j.tjog.2022.11.008.Search in Google Scholar PubMed
10. Pfaffenbach, B, Adamek, RJ, Hagelmann, D, Schaffstein, J, Wegener, M. Effect of hyperthyroidism on antral myoelectrical activity, gastric emptying and dyspepsia in man. Hepato-Gastroenterology 1997;44:1500–8.Search in Google Scholar
11. Hashem, A, Chi, MTH, Friedman, CP. Medical errors as a result of specialization. J Biomed Inf 2003;36:61–9. https://doi.org/10.1016/s1532-0464(03)00057-1.Search in Google Scholar PubMed
12. Doherty, TS, Carroll, AE. Believing in overcoming cognitive biases. AMA J Ethics 2020;22:E773-8. https://doi.org/10.1001/amajethics.2020.773.Search in Google Scholar PubMed
© 2024 Walter de Gruyter GmbH, Berlin/Boston
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- Review
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- Opinion Papers
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- Bringing team science to the ambulatory diagnostic process: how do patients and clinicians develop shared mental models?
- Vitamin D assay and supplementation: still debatable issues
- Original Articles
- Developing a framework for understanding diagnostic reconciliation based on evidence review, stakeholder engagement, and practice evaluation
- Validity and reliability of Brier scoring for assessment of probabilistic diagnostic reasoning
- Impact of disclosing a working diagnosis during simulated patient handoff presentation in the emergency department: correctness matters
- Implementation of a bundle to improve diagnosis in hospitalized patients: lessons learned
- Time pressure in diagnosing written clinical cases: an experimental study on time constraints and perceived time pressure
- A decision support system to increase the compliance of diagnostic imaging examinations with imaging guidelines: focused on cerebrovascular diseases
- Bridging the divide: addressing discrepancies between clinical guidelines, policy guidelines, and biomarker utilization
- Unnecessary repetitions of C-reactive protein and leukocyte count at the emergency department observation unit contribute to higher hospital admission rates
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- Case Report – Lessons in Clinical Reasoning
- A delayed diagnosis of hyperthyroidism in a patient with persistent vomiting in the presence of Chiari type 1 malformation
- Letters to the Editor
- Mpox (monkeypox) diagnostic kits – September 2024
- Barriers to diagnostic error reduction in Japan
- Superwarfarin poisoning: a challenging diagnosis
- Reviewer Acknowledgment
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