581
35
Clinical Section
antigen and postulated immune complex disease involving the antigen, IgM and complement. Although no precipitating cause could be found in this patient, it is interesting to note the raised IgM and lowered C3 complement, despite the fact that she was Australia antigen negative. Because we have no positive biopsy evidence we cannot place this patient's disease into a classification of necrotizing angiitis such as that suggested by Zeek (1952). Rose & Spencer (1957), however, divided their cases of polyarteritis nodosa into pulmonary and classic types. The absence of eosinophilia and lung disease in this woman suggests that we are dealing with the 'classic' rather than the 'pulmonary' disease. In this same series it was found that kidney involvement is the cause of death in 65 % of 'classical' cases. This figure is higher when hypertension secondary to kidney involvement is considered. Therefore, although the long-term prognosis is poor in this patient because of myocardial problems the outlook is brightened by the unusual and fortunate absence of overt renal disease.
One month later in England she was depressed and the gross ECG changes are illustrated in Fig 1. These changes disappeared in a period of nearly sixteen months. In January 1975 a sudden episode of mental confusion, disorientation and restlessness led to admission to St Stephen's Hospital, Fulham, where confusion and incontinence of feces and urine persisted for over a month. Investigations: ECG: normal voltage, sinus bradycardia with flat T waves in leads I, II, III, aVR, aVL, aVF. Cardiac enzymes normal. Serum sodium 114, chlorides 76 mmol/l. Other electrolytes and urea normal. Electroencephalogram (Dr N de M Rudolf) (Fig 2) one month after admission, suggested a metabolic disorder but no localized lesion. The trace was normal in October 1975 after treatment. Thyroid function: PBI 280 nmol/l, T3 resin uptake 0.91 (Thyopac-3), serum thyroxine 39 nmol/l, TSH 48 ,uu/l, 1131 uptake in the neck 10.6 %
REFERENCES
Bornie P (1972) British Journal of Dermatology 87, 87 Gocke D J, Morgan M, Lockshin M, Hsu K, Bombardieri S & Christian C L (1970) Lancet ii, 1149 Pay B W (1975) Proceedings of the Royal Society of Medicine 68, 328 Rose G A & Spencer H (I957) Quarterly Journal of Medicine 26, 43 Zeek P M (1952) American Journal of Clinical Pathology 24, 889
_I -u
~~AVL
m
~~~AVF
V.
Hypothyroidism with Episodic Psychiatric and Cardiac Manifestations P S Jayaratna MB (for B Gottlieb MD FRCP) (St Stephen's Hospital, London S WJO 9TH) M F, female aged 61 History: She had rheumatic fever at the age of 28 and a tendency to depression for fifteen years. In 1963 substernal pain required admission to hospital and the ECG showed T wave inversion in leads I, aVL, V5 and V6 with normal voltage. These changes reverted to normal in two months. The cardiac enzymes and ESR remained normal. The patient continued to have pain on effort till June 1975. In 1971 she was treated with lithium for ten weeks in a nursing home in Spain, for mental confusion and disorientation. The diagnosis was
AVR
T l||
i@.§ -B l ~~~~~H, n _ME|i
T§>- 3ZV5 F ! V _SSSr4 .1_'
V4 V2
L
- _ AV
hypomania. In 1973 she was in a coma for three days in a hospital in Paris, and the ECG showed T wave inversion in all leads. The serum sodium was 115 mEq/l but the cardiac enzymes were normal.
Fig 1 Tinversion in all leads except a VL and VI normal voltage
582
Proc. roy. Soc. Med. Volume 69 August 1976
36
1 sec
1--
2
2-+> 3
3- 4
.~~~~~~~~~~~~~~~~~~NV ,_ __ _
4~ S ' 6- 7 _ 7-+ 8
8-÷* 9 9-+ 10 NM
11-* 12
5
°
3 2 13 12-*
13-_
14
14- 15
_
vrttsAA34...#..s. [lOO1V
__ Aw
Fig 2 Generalized medium voltage slow activity (eyes closed)
at four hours. After treatment: TSH 6.3 ,uu/l, serum thyroxine 90 nmol/l. Treatment was started on 25 March 1975 with 0.025 mg thyroxine daily, the dose being increased at weekly intervals up to 0.2 mg daily. Since June 1975 she has been completely free of symptoms, both psychiatric and cardiac. The ECG was completely normal in December 1975.
unable to find any records in literature previously
of, episodic hypothyroidism. It has, however,
been shown by O'Connor et al. (1974) that acute fluctuations in the concentration of thyroid hormones in plasma occur spontaneously. It is conceivable therefore, that in certain instances this may cause hypothyroidism. This subject of pulsatile secretion of TSH and thyroid hormone is reviewed by Bondy (1975). Discussion Hypothyroidism due to lithium therapy is Asher (1949) described 14 cases of hypothyroid- reversible and patients become euthyroid within ism presenting with psychiatric symptoms; 10 of a few months of discontinuing treatment. them were admitted to a mental observation ward. Since 1971 our patient has had three major REFERENCES Asher R (1949) British Medical Journal ii, 555 episodes of mental confusion and disorientation Bondy P K (1975) Year Book of Medicine, 571 as well as minor disturbances. Cardiograms Cohen R D & Lloyd-Thomas H G (1966) British MedicalJournal ii, 327 during two of these episodes showed changes O'Connor J F, Wu G Y, Gallagher T F & Hellman L compatible with hypothyroidism. She has had (1974) Journal of Clinical Endocrinology and Metabolism 39, 765 precordial and substernal pain on effort and at rest for fifteen years. Cohen & Lloyd-Thomas (1966) demonstrated an ischemic pattern in the exercise electrocardiogram in untreated myxcedema, disappearing on treatment with thyroxine. The following case was also shown: Our patient has remained completely free of chest pain since June 1975, three months after Colonic Gas Cysts treatment with thyroxine was commenced in (Pneumatosis Cystoides Intestinalis) Mr J J Spindler (for Mr Arthur Wyatt) March 1975. Hyponatraemia is a recognized feature of (King's College Hospital, London SE5) myxoedema coma although there is no clear explanation of this phenomenon. We have been (meeting to be continued)
35
Clinical Section
antigen and postulated immune complex disease involving the antigen, IgM and complement. Although no precipitating cause could be found in this patient, it is interesting to note the raised IgM and lowered C3 complement, despite the fact that she was Australia antigen negative. Because we have no positive biopsy evidence we cannot place this patient's disease into a classification of necrotizing angiitis such as that suggested by Zeek (1952). Rose & Spencer (1957), however, divided their cases of polyarteritis nodosa into pulmonary and classic types. The absence of eosinophilia and lung disease in this woman suggests that we are dealing with the 'classic' rather than the 'pulmonary' disease. In this same series it was found that kidney involvement is the cause of death in 65 % of 'classical' cases. This figure is higher when hypertension secondary to kidney involvement is considered. Therefore, although the long-term prognosis is poor in this patient because of myocardial problems the outlook is brightened by the unusual and fortunate absence of overt renal disease.
One month later in England she was depressed and the gross ECG changes are illustrated in Fig 1. These changes disappeared in a period of nearly sixteen months. In January 1975 a sudden episode of mental confusion, disorientation and restlessness led to admission to St Stephen's Hospital, Fulham, where confusion and incontinence of feces and urine persisted for over a month. Investigations: ECG: normal voltage, sinus bradycardia with flat T waves in leads I, II, III, aVR, aVL, aVF. Cardiac enzymes normal. Serum sodium 114, chlorides 76 mmol/l. Other electrolytes and urea normal. Electroencephalogram (Dr N de M Rudolf) (Fig 2) one month after admission, suggested a metabolic disorder but no localized lesion. The trace was normal in October 1975 after treatment. Thyroid function: PBI 280 nmol/l, T3 resin uptake 0.91 (Thyopac-3), serum thyroxine 39 nmol/l, TSH 48 ,uu/l, 1131 uptake in the neck 10.6 %
REFERENCES
Bornie P (1972) British Journal of Dermatology 87, 87 Gocke D J, Morgan M, Lockshin M, Hsu K, Bombardieri S & Christian C L (1970) Lancet ii, 1149 Pay B W (1975) Proceedings of the Royal Society of Medicine 68, 328 Rose G A & Spencer H (I957) Quarterly Journal of Medicine 26, 43 Zeek P M (1952) American Journal of Clinical Pathology 24, 889
_I -u
~~AVL
m
~~~AVF
V.
Hypothyroidism with Episodic Psychiatric and Cardiac Manifestations P S Jayaratna MB (for B Gottlieb MD FRCP) (St Stephen's Hospital, London S WJO 9TH) M F, female aged 61 History: She had rheumatic fever at the age of 28 and a tendency to depression for fifteen years. In 1963 substernal pain required admission to hospital and the ECG showed T wave inversion in leads I, aVL, V5 and V6 with normal voltage. These changes reverted to normal in two months. The cardiac enzymes and ESR remained normal. The patient continued to have pain on effort till June 1975. In 1971 she was treated with lithium for ten weeks in a nursing home in Spain, for mental confusion and disorientation. The diagnosis was
AVR
T l||
i@.§ -B l ~~~~~H, n _ME|i
T§>- 3ZV5 F ! V _SSSr4 .1_'
V4 V2
L
- _ AV
hypomania. In 1973 she was in a coma for three days in a hospital in Paris, and the ECG showed T wave inversion in all leads. The serum sodium was 115 mEq/l but the cardiac enzymes were normal.
Fig 1 Tinversion in all leads except a VL and VI normal voltage
582
Proc. roy. Soc. Med. Volume 69 August 1976
36
1 sec
1--
2
2-+> 3
3- 4
.~~~~~~~~~~~~~~~~~~NV ,_ __ _
4~ S ' 6- 7 _ 7-+ 8
8-÷* 9 9-+ 10 NM
11-* 12
5
°
3 2 13 12-*
13-_
14
14- 15
_
vrttsAA34...#..s. [lOO1V
__ Aw
Fig 2 Generalized medium voltage slow activity (eyes closed)
at four hours. After treatment: TSH 6.3 ,uu/l, serum thyroxine 90 nmol/l. Treatment was started on 25 March 1975 with 0.025 mg thyroxine daily, the dose being increased at weekly intervals up to 0.2 mg daily. Since June 1975 she has been completely free of symptoms, both psychiatric and cardiac. The ECG was completely normal in December 1975.
unable to find any records in literature previously
of, episodic hypothyroidism. It has, however,
been shown by O'Connor et al. (1974) that acute fluctuations in the concentration of thyroid hormones in plasma occur spontaneously. It is conceivable therefore, that in certain instances this may cause hypothyroidism. This subject of pulsatile secretion of TSH and thyroid hormone is reviewed by Bondy (1975). Discussion Hypothyroidism due to lithium therapy is Asher (1949) described 14 cases of hypothyroid- reversible and patients become euthyroid within ism presenting with psychiatric symptoms; 10 of a few months of discontinuing treatment. them were admitted to a mental observation ward. Since 1971 our patient has had three major REFERENCES Asher R (1949) British Medical Journal ii, 555 episodes of mental confusion and disorientation Bondy P K (1975) Year Book of Medicine, 571 as well as minor disturbances. Cardiograms Cohen R D & Lloyd-Thomas H G (1966) British MedicalJournal ii, 327 during two of these episodes showed changes O'Connor J F, Wu G Y, Gallagher T F & Hellman L compatible with hypothyroidism. She has had (1974) Journal of Clinical Endocrinology and Metabolism 39, 765 precordial and substernal pain on effort and at rest for fifteen years. Cohen & Lloyd-Thomas (1966) demonstrated an ischemic pattern in the exercise electrocardiogram in untreated myxcedema, disappearing on treatment with thyroxine. The following case was also shown: Our patient has remained completely free of chest pain since June 1975, three months after Colonic Gas Cysts treatment with thyroxine was commenced in (Pneumatosis Cystoides Intestinalis) Mr J J Spindler (for Mr Arthur Wyatt) March 1975. Hyponatraemia is a recognized feature of (King's College Hospital, London SE5) myxoedema coma although there is no clear explanation of this phenomenon. We have been (meeting to be continued)
