Concurrent Event of Bilateral Pulmonary Emboli and Untreated Hyperthyroidism Causing Tachycardia in a Patient with Benign Necrotic Brain Lesion During Inpatient Rehabilitation: A Case Report

Case Diagnosis: Concurrent events of bilateral pulmonary emboli and untreated hyperthyroidism in a patient with benign necrotic brain lesion.

Case Description or Program Description: A 54-year-old male with past medical history of diabetes mellitus and asthma presented to ED because of left-side weakness. CT and MRI revealed a right frontoparietal mass suspicious of abscess or malignancy. The patient underwent craniotomy with resection of the mass and was subsequently discharged to inpatient rehabilitation. Final biopsy results confirmed the mass to be a benign necrotic lesion. Shortly after admission, patient was noted to have sinus tachycardia with hypotension which was initially thought to be orthostasis related. His tachycardia persisted despite correction of his orthostasis. After clinical record review, patient was found to have history of hyperthyroidism that was never treated. Rechecked thyroid function showed low TSH, high free T3 and T4, confirming hyperthyroidism. While patient was treated for hyperthyroidism, the d-dimer previously ordered as part of the work up for tachycardia was noted to be elevated. Patient underwent CTA which showed bilateral pulmonary emboli.

Setting: Acute inpatient rehabilitation facility

Assessment/Results: Patient was started on apixiban for pulmonary emboli and methimazole for hyperthyroidism. His symptoms improved after the treatment.

Discussion (relevance): This is a case presented with hyperthyroidism and pulmonary embolism simultaneously. Both hyperthyroidism and pulmonary embolism can cause tachycardia. Diagnosis of one condition should not preclude the clinician from pursuing other etiologies for tachycardia. Either YEARS Algorithm or Well’s score can serve as a guidance for physiatrists to decide if CTA is necessary following the result of d-dimer.

Conclusions: Hyperthyroidism and pulmonary embolism can manifest overlapping symptoms that make physiatrists overlook the possibility of a patient having concurrent medical conditions. When approaching patients with new onset of tachycardia, physiatrists should consider d-dimer and thyroid studies to screen for pulmonary embolism and hyperthyroidism, respectively.