An Atypical Presentation of Apathetic Thyrotoxicosis Requiring Thyroidectomy In The Acute Setting

Apathetic thyrotoxicosis is an atypical manifestation of thyrotoxicosis characterized by depression, lethargy, and weakness.1 Patients are often elderly and have no known history of hyperthyroidism. Typical symptoms of hyperthyroidism such as hyperkinetic motor activity and exophthalmos are often absent. In the classical description, apathetic thyrotoxicosis is a distinct clinical entity, however the end stage presentation of typical thyrotoxicosis may result in apathy with considerable overlap in clinical features. This unique case illustrates a scenario in which untreated typical thyrotoxicosis progressed to an apathetic state, thus suggesting that apathetic thyrotoxicosis and end stage untreated thyrotoxicosis may be variations of the same disease process rather than distinct clinical entities. Here we present a 53 year old woman with typical Graves’ disease, treated initially with methimazole. She developed methimazole-induced agranulocytosis, requiring cessation of treatment. After a period of inadequate treatment, she represented in a clinically apathetic state, with biochemically uncontrolled hyperthyroidism. Following emergent medical stabilization, she successfully underwent definitive total thyroidectomy.