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What Causes Severe Fever And Constipation When Diagnosed With Hypothyroidism?
Question: My mother (58+ yrs) is under treatment for Hypothyroidism (Eltroxin 50 mcg), Hypertension (Olmezest 20 mg), Osteoarthritis (stage-2) of knee joints (Gemcal D3). She also takes 'Uprise XT' & 'Folvite' for treatment of mild anemia (Hb 10.7) over past 3-4 months. I would request your review of couple of incidents in last couple of months & few symptoms after that to make sure we are on the right track of treatment -
Incident #1
=========
Couple of months back, while she had fever (up to 101 F) due to cough & cold, on the 3rd day morning, after breakfast, she had reported to feel 'chakkar' (reeling of head) with dark vision in the sitting position itself, which subsided after she went to bed. On the same evening, she had to visit the doctor for fever, who reported BP 130/80 (sitting position - left arm) & pulse 102 & had prescribed 'Moxclav 625' thrice daily for 5-days.
Incident #2
=========
About 3-weeks back, she also had mild cold, which got subsided with 2-tablets of 'cetzine'. On the following day, after lunch, she had again reported to feel 'chakkar' (reeling of head) with dark vision in the sitting position itself, after which she was bent in left side & was almost about to fall down from the chair (which we had stopped) along with her left hand shaking for 15-20 sec. We felt she had gone to some sort of subconscious state for 3-4 mins & when we tried to talk to her, initially she just made some strange sounds, followed by some proper words but in a strange voice, after which she suddenly became normal & started talking clearly. However, she was crying & worrying about the ongoing health problems at home & mentioned that she did not have any memory of the incident at all. She was back to normal activities in next 10 mins.
Post incident symptoms
====================
1) For 2-weeks after the 2nd incident, she was extremely tired (to do regular household work) & used to feel sleepy in early evening itself. Things are little improved since this week, however, she still had quite some amount of fatigue.
2) After the 2nd incident, we noticed her to have frequent constipation for 2-3 days followed by 5-6 times of motion (not necessarily loose motion) on a day. However, on the next day, she reported to feel lot of heaviness in forehead portion along with heaviness in legs, which made her walking & daily activities really difficult. These symptoms already appeared twice in past 2-weeks & subsided in couple of days.
3) Lost weight (69.5 -> 66.5 KG) in past 2-months.
Doctor's Advice
===============
We had visited our medicine doctor after 5-6 days of the 2nd incident, who noted BP 122/82 (sleeping position - right arm) & asked for sodium (138) & potassium (3.7) reports. He had also advised to take water with salt/sugar & avoid dairy products. Due to the recurrent weakness, he had also suggested a neurologist review of her food supplements as follows -
1) Gemcal D3 (taking past 5-years)
2) Uprise XT (taking past 3-4 months)
3) Folvite (taking past 3-4 months)
4) Ensure Plus 3 TSP BD (added in last visit)
Reports (3-month old)
=====================
TSH - 3.75
FBS - 97
VitD - 43
Hb - 11.2
My concern is whether or not we are on the right track of treatment specially in terms of incident #2 ? Could it really be a case of stroke or TIA or something serious, which we could have overlooked ?
Incident #1
=========
Couple of months back, while she had fever (up to 101 F) due to cough & cold, on the 3rd day morning, after breakfast, she had reported to feel 'chakkar' (reeling of head) with dark vision in the sitting position itself, which subsided after she went to bed. On the same evening, she had to visit the doctor for fever, who reported BP 130/80 (sitting position - left arm) & pulse 102 & had prescribed 'Moxclav 625' thrice daily for 5-days.
Incident #2
=========
About 3-weeks back, she also had mild cold, which got subsided with 2-tablets of 'cetzine'. On the following day, after lunch, she had again reported to feel 'chakkar' (reeling of head) with dark vision in the sitting position itself, after which she was bent in left side & was almost about to fall down from the chair (which we had stopped) along with her left hand shaking for 15-20 sec. We felt she had gone to some sort of subconscious state for 3-4 mins & when we tried to talk to her, initially she just made some strange sounds, followed by some proper words but in a strange voice, after which she suddenly became normal & started talking clearly. However, she was crying & worrying about the ongoing health problems at home & mentioned that she did not have any memory of the incident at all. She was back to normal activities in next 10 mins.
Post incident symptoms
====================
1) For 2-weeks after the 2nd incident, she was extremely tired (to do regular household work) & used to feel sleepy in early evening itself. Things are little improved since this week, however, she still had quite some amount of fatigue.
2) After the 2nd incident, we noticed her to have frequent constipation for 2-3 days followed by 5-6 times of motion (not necessarily loose motion) on a day. However, on the next day, she reported to feel lot of heaviness in forehead portion along with heaviness in legs, which made her walking & daily activities really difficult. These symptoms already appeared twice in past 2-weeks & subsided in couple of days.
3) Lost weight (69.5 -> 66.5 KG) in past 2-months.
Doctor's Advice
===============
We had visited our medicine doctor after 5-6 days of the 2nd incident, who noted BP 122/82 (sleeping position - right arm) & asked for sodium (138) & potassium (3.7) reports. He had also advised to take water with salt/sugar & avoid dairy products. Due to the recurrent weakness, he had also suggested a neurologist review of her food supplements as follows -
1) Gemcal D3 (taking past 5-years)
2) Uprise XT (taking past 3-4 months)
3) Folvite (taking past 3-4 months)
4) Ensure Plus 3 TSP BD (added in last visit)
Reports (3-month old)
=====================
TSH - 3.75
FBS - 97
VitD - 43
Hb - 11.2
My concern is whether or not we are on the right track of treatment specially in terms of incident #2 ? Could it really be a case of stroke or TIA or something serious, which we could have overlooked ?
Brief Answer:
Brain imaging is recommended
Detailed Answer:
I read your question carefully and I understand your concern.
The first incident is not very specific, meaning could be caused by many different situations, the most likely cause given the fact she improved after lying down would be a temporary drop in blood pressure, which was transitory and not present in the later measurement.
The second incident though is a little worrying. Judging from your description it would seem likely for it to have been a seizure. Seizures can have many causes. At times no cause can be identified, in particular in cases where they appear from childhood. However, when they appear at such a late age an identifiable cause is much more likely and it should be investigated. Most common causes may include brain lesions such as stroke or tumor. At times narrowing of the neck vessels may lead to insufficient blood supply to the brain and lack of oxygen as well. Given her history of hypothyroidism metabolic abnormalities and anemia are also to be considered but seeing those lab reports it doesn't seem likely.
So I would strongly recommend a neurologist consult as well in order to search for other subtle neurological signs you might have missed and to consider the possibility of scheduling imaging of the brain and its supplying vessels.
I remain at your disposal for other questions.
Brain imaging is recommended
Detailed Answer:
I read your question carefully and I understand your concern.
The first incident is not very specific, meaning could be caused by many different situations, the most likely cause given the fact she improved after lying down would be a temporary drop in blood pressure, which was transitory and not present in the later measurement.
The second incident though is a little worrying. Judging from your description it would seem likely for it to have been a seizure. Seizures can have many causes. At times no cause can be identified, in particular in cases where they appear from childhood. However, when they appear at such a late age an identifiable cause is much more likely and it should be investigated. Most common causes may include brain lesions such as stroke or tumor. At times narrowing of the neck vessels may lead to insufficient blood supply to the brain and lack of oxygen as well. Given her history of hypothyroidism metabolic abnormalities and anemia are also to be considered but seeing those lab reports it doesn't seem likely.
So I would strongly recommend a neurologist consult as well in order to search for other subtle neurological signs you might have missed and to consider the possibility of scheduling imaging of the brain and its supplying vessels.
I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thanks Doctor. Few more follow up questions for you -
1) As you mentioned for seizures, most common causes may include brain lesions such as stroke or tumor, does it mean the 2nd incident could be a stroke as well ? Or, do you mean some stroke might have occurred in the past ?
2) Until all brain related investigations are done, do you recommend to continue the medicine Folvite ? Does it have any risk for such incidents ?
3) What could have been the cause for the post incident symptoms e.g. heaviness in head, heaviness in legs & difficulty to walk etc specially after she had 5-6 times motion a day ? Is it due to potassium level (3.7) ?
1) As you mentioned for seizures, most common causes may include brain lesions such as stroke or tumor, does it mean the 2nd incident could be a stroke as well ? Or, do you mean some stroke might have occurred in the past ?
2) Until all brain related investigations are done, do you recommend to continue the medicine Folvite ? Does it have any risk for such incidents ?
3) What could have been the cause for the post incident symptoms e.g. heaviness in head, heaviness in legs & difficulty to walk etc specially after she had 5-6 times motion a day ? Is it due to potassium level (3.7) ?
Brief Answer:
Your answers as follows.
Detailed Answer:
The answers to your questions as follows:
1. Actually both hypotheses are possible. An acute as well as a past stroke both can cause seizures. An acute stroke may do that due to the acute changes and disrupted connections, while a past stroke can cause seizures as the new connections formed during the recovery process are more easily excited, more prone to abnormal electrical discharges. So both are possible, a stroke happening in areas which do not cause evident deficits like paralysis may be discovered by a seizure.
2. Yes I do not see any harm at all from Folvite. It is folic acid, simply a vitamin, a naturally occurring substance found in food as well. No harm comes from it.
3. It is tough to say, several possibilities. One possibility is having frequent motion may have caused temporary dehydration which does justify the symptoms. If a stroke happened they might simply be due to the damage to the brain caused by it. Seizures themselves may cause some transitory muscle damage due to the convulsions which may lead to weakness and heaviness afterwards. May cause some brain swelling as well which also can justify the symptoms. At the end of the day may be some other passing cause like a viral infection, may be impossible to confirm now. I do not think it was due to low potassium, reference range is 3.5-5.1 mEq/L or mmol/L, so that value would be normal (unless you use some other measuring system with different reference ranges in India).
I hope to have been of help.
Your answers as follows.
Detailed Answer:
The answers to your questions as follows:
1. Actually both hypotheses are possible. An acute as well as a past stroke both can cause seizures. An acute stroke may do that due to the acute changes and disrupted connections, while a past stroke can cause seizures as the new connections formed during the recovery process are more easily excited, more prone to abnormal electrical discharges. So both are possible, a stroke happening in areas which do not cause evident deficits like paralysis may be discovered by a seizure.
2. Yes I do not see any harm at all from Folvite. It is folic acid, simply a vitamin, a naturally occurring substance found in food as well. No harm comes from it.
3. It is tough to say, several possibilities. One possibility is having frequent motion may have caused temporary dehydration which does justify the symptoms. If a stroke happened they might simply be due to the damage to the brain caused by it. Seizures themselves may cause some transitory muscle damage due to the convulsions which may lead to weakness and heaviness afterwards. May cause some brain swelling as well which also can justify the symptoms. At the end of the day may be some other passing cause like a viral infection, may be impossible to confirm now. I do not think it was due to low potassium, reference range is 3.5-5.1 mEq/L or mmol/L, so that value would be normal (unless you use some other measuring system with different reference ranges in India).
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thanks Doctor for your detailed response. Couple of more things I wanted to mention if they give any further input -
1) She did not have that much convulsion during the incident, except the left hand (from wrist to palm) was shaking for 15-20 sec, after which she was about to fall. Our medicine doctor has also mentioned "No H/O Convulsion" in his prescription.
2) She had cataract surgery (soft) for both of her eyes in Nov, 2016 thru Phaco method. Is it somehow related to the incident ?
1) She did not have that much convulsion during the incident, except the left hand (from wrist to palm) was shaking for 15-20 sec, after which she was about to fall. Our medicine doctor has also mentioned "No H/O Convulsion" in his prescription.
2) She had cataract surgery (soft) for both of her eyes in Nov, 2016 thru Phaco method. Is it somehow related to the incident ?
Brief Answer:
Read below.
Detailed Answer:
Thank you for the additional information.
1. Short as it may have been I still think that the most likely nature of the episode was a seizure, not only from the shaking but also by your description of the subsequent minutes. Your doctor seems to think otherwise, but I do not see how he can be so certain, one may have doubts but it's hard to speak with certainty when it comes to seizures.
2. As for the cataract surgery I don't think it is related to the incident.
Let me know if I can further assist you.
Read below.
Detailed Answer:
Thank you for the additional information.
1. Short as it may have been I still think that the most likely nature of the episode was a seizure, not only from the shaking but also by your description of the subsequent minutes. Your doctor seems to think otherwise, but I do not see how he can be so certain, one may have doubts but it's hard to speak with certainty when it comes to seizures.
2. As for the cataract surgery I don't think it is related to the incident.
Let me know if I can further assist you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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