Missing the boat

One of my partners was asked to see a hyperthyroidism consult in the hospital the other day. A 30-something year old woman with Graves' disease, who was admitted with a large left hemispheric stroke.

I was horrified and deeply saddened when I heard about her. Because she was so young. Because her life which was so full of potential, has drastically changed probably forever. She could not walk (perhaps with therapy, might recover some degree of ambulation in the future), could not move her right arm, and had marked aphasia (speech). Mother of 2 young kids. And because the stroke could have been prevented.

Turns out, I had seen her in clinic 6 years ago, and made the diagnosis of Graves' disease. The biochemistry, clinical picture and the I123 scan were classic. I started her on antithyroid therapy. At follow up 2 months later, her labs actually looked worse- she had not been compliant with her medications because like many others, she did not want to gain weight as we corrected her thyroid and slowed her metabolism back to a normal level. I never saw her again- she subsequently no-showed visits and was lost to follow up. And while this was a rare, severe complication of untreated hyperthyroidism, unfortunately it happened.

Was the stroke caused by the hyperthyroidism? Probably- she was young with no other risk factors. She was in a-fib when she presented, with FT4 levels 8 times where it should have been. It was clear this was a causative factor.

She promised to be compliant with treatment this time; but a huge part of me was saddened to think of how things could have been if that was the approach 6 years ago, and while it'll be helpful to be on medications now, the truth is we've already missed the boat and the damage has been done.

I only hope that with her youth, physical therapy is able to help her recover some meaningful use of the right side of her body.