Real Practice Assessment of Persistent Symptoms After Initiation of Levothyroxine.

OBJECTIVE: Levothyroxine (LT4) is the standard treatment for hypothyroidism. However, certain patients experience persistent symptoms even after achieving euthyroid status with LT4 therapy. We aimed to determine the frequency of persistent or new symptoms in patients with hypothyroidism after initiating LT4. METHODS: This retrospective study included patients with hypothyroidism who started on LT4 between January 2017 and December 2019 at Mayo Clinic in Rochester, Minnesota, USA. Five hundred patient charts were randomly selected for review. Patients with at least 1 documented follow-up encounter after LT4 initiation were evaluated for ≤3 follow-up visits regarding their biochemical status and symptoms. RESULTS: We included 356 patients, a majority of whom were female (66.6%), white (92.3%), and obese (71.9%), with an average age of 59.5 years. At the baseline visit, approximately one-half of the patients (177/356, 47.7%) reported hypothyroid symptoms, with fatigue being the most common symptom. During the follow-up periods, we observed that 17.8% (28/157), 17.9% (19/106), and 19.3% (11/57) of patients had normal thyroid stimulating hormone (TSH) values but persistent symptoms, while 12.3% (19/156), 19.9% (16/107), and 8.9% (5/56) had normal TSH values but new symptoms. Overall, during each respective follow-up period, 26.7% (42/157), 27.3% (29/106), and 28% (16/57) of patients experienced persistent or new symptoms alongside normal TSH values, with fatigue being the most constant symptom. CONCLUSION: Our findings indicate that approximately 1 in every 4 patients with hypothyroidism receiving LT4 therapy and achieving normal TSH levels experience persistent or new hypothyroid symptoms. The cause of these symptoms remains unclear, emphasizing the need for a better understanding of their underlying causes and the development of effective management strategies.

Case Report of Retarded Catatonia: Always Consider Catatonia as a Differential Diagnosis of Altered Mental Status.

BACKGROUND: Catatonia is a rare neuropsychiatric condition; it is estimated that around 10% of patients with mood disorders present signs and symptoms of catatonia. A catatonic syndrome is characterised by mutism, negativism, rigidity, and stupor. CASE REPORT: We report the case of a 59-year-old patient with a medical history of bipolar disorder who was admitted to the internal medicine service due to a seizure episode. During hospitalisation, the patient presented significant worsening of her clinical condition, showing marked symptoms of stupor and catatonia. Once the neurological and metabolic etiologies of altered mental status had been ruled out, pharmacological treatment with high doses of lorazepam was started. The patient had a complete clinical remission, and her evolution was favourable without any complications. Electroconvulsive therapy was recommended as a definitive treatment. CONCLUSIONS: The diagnosis of catatonia is a challenge for both hospitalists and psychiatrists due to the clinical presentation of catatonia. In reporting this clinical case, we want to emphasise the importance of taking into account the catatonic syndrome in our differential diagnoses in patients with altered mental status.

Case Report of Retarded Catatonía: Always Consider Catatonía as a Dífferentíal Diagnosis of Altered Mental Status / Informe de un caso de catatonia retardada: Considerar siempre la catatonia como diagnóstico diferencial de la alteración del estado mental

ABSTRACT Background: Catatonia is a rare neuropsychiatric condition; it is estimated that around 10% of patients with mood disorders present signs and symptoms of catatonia. A catatonic syndrome is characterized by mutism, negativism, rigidity, and stupor. Case report: We report the case of a 59-year-old patient with a medical history of bipolar disorder who was admitted to the internal medicine service due to a seizure episode. During hospitalisation, the patient presented significant worsening of her clinical condition, showing marked symptoms of stupor and catatonia. Once the neurological and metabolic etiologies of altered mental status had been ruled out, pharmacological treatment with high doses of lorazepam was started. The patient had a complete clinical remission, and her evolution was favourable without any complications. Electroconvulsive therapy was recommended as a definitive treatment. Conclusions: The diagnosis of catatonia is a challenge for both hospitalists and psychiatrists due to the clinical presentation of catatonia. In reporting this clinical case, we want to emphasize the importance of taking into account the catatonic syndrome in our differential diagnoses in patients with altered mental status.

RESUMEN Introducción: La catatonía es una condición neuropsiquiátrica poco frecuente, se estima que cerca del 10% de los pacientes con trastornos afectivos presentan signos y síntomas de catatonía. El síndrome se caracteriza clínicamente por mutismo, negativismo, rigidez y estupor. Caso clínico: Se describe el caso clínico de una paciente de 59 años con antecedentes de trastorno bipolar, ingresada por el servicio de medicina interna por un episodio de crisis convulsiva. Durante la hospitalización, la paciente presentó un importante deterioro clínico, marcado estupor y síntomas de catatonía. Una vez descartadas etiologías neurológicas y metabólicas de la alteración del estado de conciencia, se inició el tratamiento farmacológico con altas dosis de lorazepam. El cuadro clínico de la paciente evolucionó favorablemente con una remisión clínica completa. Conclusiones: El diagnóstico de catatonía constituye un reto tanto para médicos internistas como psiquiatras por su presentación clínica. Con el reporte de este caso clínico se desea enfatizar la importancia de considerar al síndrome catatónico en nuestros diagnósticos diferenciales en pacientes con alteración del estado de conciencia.