Nausea and vomiting as major presenting symptoms of thyrotoxicosis after bilateral adrenalectomy for Cushing's disease

Yana Kogan, Nizar Elias, Mohammad Sheikh-Ahmad, Majed Odeh


Thyrotoxicosis has a variety of presentations which depend on its severity and duration, as well as the age of the patient. In elderly patients, thyrotoxicosis may present with a variety of nonspecific symptoms. Nausea and vomiting as major presenting symptoms of thyrotoxicosis have rarely been reported. Thyrotoxicosis after adrenalectomy in patients with Cushing's syndrome and normal thyroid function, or with autoimmune thyroid dysfunction has rarely been reported previously. We describe a very rare case of an elderly patient with hypothyroidism due to Hashimoto's thyroiditis who presented with persistent nausea and vomiting as major presenting symptoms of thyrotoxicosis, which developed after bilateral adrenalectomy for Cushing's disease. Similar case has not been reported previously. In reporting this patient we aim at drawing attention to these forgotten symptoms of thyrotoxicosis, nausea and vomiting, and to emphasize that, at times, these symptoms may be the only presenting features of thyrotoxicosis, leading to considerable difficulty in diagnosis. Furthermore, cessation of glucocorticoid excess may sometimes be accompanied with thyrotoxicosis.


Cushing's syndrome adrenalectomy, Nausea, Thyrotoxicosis, Vomiting

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Jameson JL, Mandel SJ, Weetman AP. Disorders of the thyroid gland. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 19th ed. New York: McGraw-Hill;2015:2283-2308.

Mooradian AD. Asymptomatic hyperthyroidism in older adults: is it a distinct clinical and laboratory entity. Drugs Aging. 2008;25:371-80.

Harper MB. Vomiting, nausea, and abdominal pain: unrecognized symptoms of thyrotoxicosis. J Fam Pract. 1989;29:382-6.

Sathyakumar S, Shetty S, Kapoor N, Abraham S, Paul TV. An uncommon cause for vomiting. J Family Med Prim Care. 2016;5:704-5.

Jearraksuwan S, Sridama V, Piriyawat P, Snaboon T. Vomiting and hiccups as the first presentation of thyrotoxicosis. Am J Med. 2015;128:e5-e6.

Chen P, Chen HF, Tan SW, Su MC, Ng KW, Jian CF. Severely sustained vomiting as the main symptom in a man with thyrotoxicosis. J Chin Med Assoc. 2003;66:311-4.

Shim S, Ryu HS, Oh HJ, Kim YS. Thyrotoxic vomiting: a case report and possible mechanisms. J Neurogastroenterl Motil. 2010;16:428-32.

Chen LY, Zhou B, Chen ZW, Fang LZ. Recurrent severe vomiting due to hyperthyroidism. J Zhejiang Univ Sci B. 2010;11:218-20.

Hoogendoorn EH, Cools BM. Hyperthyroidism as a cause of persistent vomiting. Neth J Med. 2004;62:293-6.

Parkin AJ, Nisbet AP, Bishop N. Vomiting due to gastric stasis as the presenting feature of thyrotoxicosis. Postgrad Med J. 1981;57:405.

Mandel SJ, Larsen PR, Davies TF. Throtoxicosis. In: Melamed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia, PA: Elsevier Saunders;2011:362-405.

Hsiao FC, Hung YJ, Hsieh CH, Wu LY, Shih KC, He CT. Abdominal pain and multi-organ dysfunction syndrome in a young woman. Am J Med Sci. 2007;334:399-401.

Burch HB, Wartofsky L. Life-threatening thyrotoxicosis: thyroid storm. Endocrino Metab Clin North Am. 1993;22:263-77.

Rosei CA, Capelli C, Salvetti M, Castellano M, Muiesan ML, Rosei EA. The unusual clinical manifestation of thyroid storm. Intern Emerg Med. 2011;6:385-7.

Osler W. The principles and Practice of Medicine. 6th ed. New York, Appleton;1907:763-771.

Cameron AT. Recent Advances in Endocrinology. 5th ed. Churchill, London;1945:376.

Gargill SL, Lesses MF. Disease of the Thyroid Gland, Oxford University Press. New York. 1955:68.

Means JH, de Groot LJ, Stanbury JB. The Thyroid and its Diseases, 3rd ed. McGrqw-Hill, New York;1963:128.

Valentine BH, Jones C, Tyack AJ. Hyperemesis gravidarum due to thyrotoxicosis. Postgrad Med J. 1980;56:746-7.

Dozeman R, Kaiser FE, Cass O, Pries J. Hyperthyroidism appearing as hyperemesis gravidarum. Arch Intern Med. 1983;143;2202-3.

Jeffcoate WJ, Brain C. Recurrent pregnancy-induced thyrotoxicosis presenting as hyperemesis gravidarum. Br J Obstet Gynecol. 1985;92:413-5.

Duick DS, Wahner HW. Thyroid axis in patients with Cushing’s syndrome. Arch Intern Med. 1979;138:767-72.

Degroot LJ, Hoye K. Dexamethasone suppression of serum T3 and T4. J Clin Endocrinol Metal. 1976;42:976-8.

Oppenheimer JH, Werner SC. Effect of prednisone on thyroxine-binding proteins. J Clin Endocrinol Metal. 1966;26:715-21.

Roelfsema F, Pereira AM, Biermasz NR, Frolich M, Keenan DM, Veldhuis JD, Romijn JA. Diminished and irregular TSH secretion with delayed acrophase in patients with Cushing's syndrome. Eur J Endocrinol. 2009;161:695-703.

Robello D, Sonino N, Casara D, Girelli ME, Busnardo B, Boscaro M. Acute and chronic effects of high glucocorticoid levels on hypothalamic-pituitary-thyroid axis in man. J Endocrinl Invest. 1992;15:437-41.

Haraguchi K, Hiramatsu K, Onaya T. Transient thyrotoxicosis after unilateral adrenalectomy in two patients with Cushing's syndrome. Endocrinol JPN. 1984;31:577-82.

Yamakita N, Sakata S, Hayashi H, Maekawa H, Miura K. Case report: silent thyroiditis after adrenalectomy in a patient with Cushing's syndrome. Am J Med Sci. 1993;305:304-6.

Takasu N, Komia I, Nagasawa Y, Asawa T, Yamada T. Exacerbation of autoimmune thyroid dysfunction after unilateral adrenalectomy in patients with Cushing's syndrome due to an adrenocortical adenoma. N Engl J Med. 1990;322:1708-2.

Takasu N, Ohara N, Yamada T, Komiya I. Development of autoimmune thyroid dysfunction after bilateral adrenalectomy in a patient with Carney's complex and after removal of ACTH-producing pituitary adenoma in a patient with Cushing's disease. J Endocrinol Invest. 1993;16:691-702.

Rosenthal FD, Jones C, Lewis SI. Thyrotoxic vomiting. Br Med J. 1976;2:209-11.

Groskreutz JL, Kim CH, McConahey WM. Acute gastroparesis associated with thyrotoxicosis. Am J Gastroenterol. 1990;85:1206-7.

Baxter JD, Bondy PK. Hypercalcemia of thyrotoxicosis. Ann Intern Med. 1966;65:429-42.

Gordon DL, Suvanich S, Erviti V, Schwartz MA, Martinez CJ. The serum calcium level and its significance in hyperthyroidism: a prospective study. Am J Med Sci. 1974;268:31-6.

Wang KW, Mui KS. Thyrotoxic Hyperemesis: a case report. Singapore Med J. 1989;30:493-4.